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UNIVERSITY OF SOUTHAMPTON
FACULTY OF HEALTH SCIENCES
Podiatry and Diabetes: An Exploration in Specialisation
By
Dawn Bacon
A thesis submitted for the degree of Doctor of Philosophy.
September 2011
i
UNIVERSITY OF SOUTHAMPTON
ABSTRACT
FACULTY OF HEALTH SCIENCES
Doctor of Philosophy
PODIATRY AND DIABETES: AN EXPLORATION IN SPECIALISATION
By Dawn Bacon
Within healthcare, the concept of specialisation remains both poorly defined and
under-debated in the literature. This research analyses the concept of specialisation
and assesses the maturity of the concept of the diabetes specialist podiatrist; tracing
the origins, change over time and current status of podiatric specialisation in diabetes.
Literature pertaining to the legal implications of specialist practice, settings and titles
is reviewed and a definition of specialisation within the context of healthcare is
proposed.
The initial concept analysis led to refinement of research questions which directed
further enquiry. Because answers to the research questions lie within the knowledge
and experiences of key actors, managers and individual podiatrists who have held
specific posts; a qualitative methodology featuring focus group and key actor
interviews was utilised. The meaning of podiatric specialisation in diabetes, how
diabetes evolved as a podiatric specialty, the impact of specialist titles and the longer-
term, wider implications which accompany specialisation were explored. In
presenting analysis of the data, the researcher focuses on theory which illuminates the
findings. The centrality of Weber’s concept of charismatic authority to the
development and contemporary face of specialist practice is illustrated by the data;
thus it represents a guiding theoretical concept within the author’s thesis.
Documentary analysis was used as a triangulation strategy, in a bid to corroborate
findings elicited through interview techniques. The documentary data also illustrates
both the scale of and the context within which podiatric specialisation in diabetes
evolved – not in isolation, but rather as one of many specialist foci.
ii
Table of contents: Page
List of tables, graphs and illustrations viii
Author’s Declaration x
Acknowledgements xi
1.0 LITERATURE REVIEW 1.1 Introduction to the Literature Review 1
1.1.1 Concept Analysis 1 1.1.2 The Concept of Specialisation 1
1.2 Specialisation in the Context of Healthcare 3
1.3 Related Case: Medical Specialisation 5
1.3.1 Diabetology (medical specialisation in diabetes) 9 1.3.2 General practitioners with special interest in diabetes 10
1.4. Related Case: Nurse Specialisation 12
1.4.1 Diabetes Specialist Nurses 14
1.5 Podiatric Specialisation 16 1.5.1 Prescribing 17
1.5.2 Special Interest Groups 17 1.5.3 The Establishment of Podiatric Surgery 18
1.5.4 Diabetes Specialist Podiatrists 19 1.5.4.1 Drivers for Specialisation in Diabetes Podiatry 20
1.5.5 Foot in Diabetes UK 22 1.5.6 Education and Career Pathways in Diabetes Podiatry 24
1.5.6.1 Establishment of a Diabetes Specialist Podiatry Assistant Grade 24 1.5.7 The Image of Diabetes Podiatry 25
1.6 Specialisation and Specialist - Pragmatic Utility and a proposed definition 26
1.6.1 Comparative Concept Maturity Matrices 28 1.6.2 Maturity of the Concept of Diabetes Specialist Podiatry 41
1.6.2.1 Preconditions of Specialised Practice in Diabetes 41 1.6.2.2 Characteristics of Specialised Practice in Diabetes 41
1.6.2.3 Outcomes and Consequences of Specialised Practice in Diabetes 44 1.6.3 Conceptual Maturity of Diabetes Specialist Podiatry 46
1.7 Specialisation – Overview of Theoretical Frameworks 46 1.7.1 Development of Specialised Practice 48
1.7.1.1 Theories of Phasic Development 50 1.7.2 Unique Knowledge, Skills and Practices 51
1.7.2.1 Training and Accreditation 52 1.7.2.2 Research 53
1.7.3 Stratification of Roles and Functions 54 1.7.3.1 Implications of Role Stratification 54
1.7.3.2 Negotiating Roles 55 1.7.3.3 A Note on Negotiated Order Theory 56
iii
1.7.4 Recognition of Specialisation 57
1.7.5 The Professional Project 57 1.7.5.1 The Professional Project, Class and Politics 58
1.8 Medical Dominance 59
1.8.1 Foundations of Medical Dominance 60 1.8.1.1 Professionalism 60
1.8.1.2 Blending Knowledge and Mystery 60 1.8.1.3 Closure Theory 61
1.8.1.4 Hegemony 62 1.8.2 Medical Dominance, Declining or Changing? 62
1.8.2.1The Case for Declining Medical Dominance 63 1.8.2.2 The Case for Changing Medical Dominance 63
1.8.3 Podiatry and Medical Authority 65 1.8.3.1 Governance 65
1.8.3.2 Collaborative Healthcare Teams and Medical Dominance 65 1.8.3.3 Podiatric Challenges to Medical Authority 66
1.8.3.4 The Legacy of Challenging Medical Authority 66 1.8.4 Conclusion 67
1.9 Legal Implications of Specialisation 68
1.9.1 The Law, Specialist Resources and Commissioning of Specialist Services 69 1.9.2 The Law and Community Based Diabetes Specialist Podiatry 69
1.9.3 The Law and Diabetes Specialist Podiatrists in Multi-Disciplinary Teams 70
1.10 Charismatic Authority 71 1.10.1 The Concept of Charisma and its early Origins 71
1.10.2 Authority 72 1.10.3 Charismatic Authority 73
1.10.4 Dissemination and Discipleship 74 1.10.5 Fragility of Charismatic Forms of Authority 75
1.10.6 Succession 75 1.10.7 Routinisation 75
2.0 METHODOLOGY 2.0 Overview of the Research 77 2.1 Philosophy 77
2.2 Concepts 78 2.2.1 Analysing Concepts – the Philosophical Background 78
2.3 Concept Analysis 79 2.3.1 The Origins of Concept Analysis 80
2.3.2 Development, change over time and models of concept analysis 80 2.3.2.1 Norris 81
2.3.2.2 Chinn and Jacobs 81 2.3.2.3 Chinn and Kramer 82
2.3.2.4 Walker and Avant 83 2.3.2.5 Rodgers 84
2.3.2.6 Morse 85 2.3.4 Concept analysis – Summary 87
iv
2.4 Sampling Strategy 87 2.4.1 Purposive, Criterion Based Sampling 87
2.4.1.1Snowball Sampling 87 2.4.2 Sample Size 88
2.5 Interviews 88
2.5.1 Focus Group Interview 89 2.5.2 Key Actor Interview 90
2.5.3 Negative aspects of interview methodology 90
2.6 Coding 90 2.6.1.1 Open Coding 90
2.6.1.2 Axial or Focussed Coding 91 2.6.2 Data Analysis 91
2.6.2.1 Constant Comparative Method 92 2.6.2.2 Verstehen 93
2.6.3 Reduction 94 2.6.3.1 Data Matrix 94
2.7 Triangulation 94
2.8 Documentary Analysis 95
2.8.1 Content analysis – qualitative or quantitative? 96 2.8.2 Problems with Content Analysis 97
2.8.3 Content Analysis – Ontology 98 2.8.4 Content Analysis – Epistemology 98
2.8.5 Content Analysis – Limitations 99
2.9 Research Governance 100 2.9.1Confidentiality and Anonymity 100
2.9.2 Data Protection 101
3.0 METHODS 3.1 Ontological and Epistemological Underpinnings 103
3.1.1 Initial Research Interest 103
3.2 Literature Review 104 3.2.1Research Aims 104
3.3 Concept Analysis 104
3.4 Choice of Data Collection Methods 105
3.5 Recruitment 105 3.5.1Rationale for Sampling Strategy 106
3.6 Interview Schedules 106
v
3.7 Research Governance 107 3.7.1Ethical Approval 107
3.7.2 Informed Consent, Confidentiality and Anonymity 107
3.8 Piloting 108
3.9 Change of Methodology in Response to Practicalities 108
3.10 Data Gathering 109 3.10.1 On-going Recruitment 110
3.11 Data Handling 111
3.12 Data Analysis, Rationale 112
3.12.1Verstehen 112
3.13 Presentation of the data 113
3.14 Triangulation – Documentary Analysis 113 3.14.1 Documentary Sample 113
3.14.2 Documentary Data Collection 115 3.14.3 Inferences 115
3.14.4 Analysis of the Documents 116
FINDINGS AND DISCUSSION
4.0Charismatic Authority and Medical Patronage 117
4.1 The Role of Charismatic Authority in Developing Specialist Practice 117
4.1.1 The Emergence of Diabetes Podiatry as a Specialty 117 4.1.1.1 Icons and Role Models 119
4.2 Medical Patronage 121
4.2.1 Combined Effects – Charismatic Authority and Medical Patronage 123
4.3 Change Over Time 125 4.3.1 The Impact of Confidence “Pushing the Boundaries” 126
4.3.2 Challenging Practice 127
4.4 The Continued Role of Charisma 128 4.4.1 Succession 129
4.5 Continued Medical Patronage 130
4.6 The Influence of Charisma 133
4.6.1 Charismatic Potential and Entry into Diabetes Podiatry 134 4.6.2 Influence of Charisma on the Level of Clinical Practice 135
4.6.3 Influence of Charisma on Interaction with Other Professionals 136
vi
4.6.4 Networking 137
4.7 Charismatic Authority and Medical Patronage; Tensions, Limitations
and Constraints 138 4.7.1 Containing Charismatic Authority 138
4.7.1.1 Admission Rights 139 4.7.2.2 Supplementary Prescribing 140
4.7.2 Loss of Medical Patronage 141
4.8 Sustainability of diabetes podiatry 142 4.8.1 Lack of Faculty Status 142
4.8.2 Fragility of Charismatic Authority 143 4.8.3 Routinisation 143
4.9 The Importance of Medical Patronage 146
4.10 Why has Charisma Been Such an Important Influence? 147
5.0 TITLE 151
5.1 The Variety of Titles in Diabetes Podiatry 151
5.2 “Specialist” Titles 152 5.2.1 Origins and Meanings of specialist Titles in Diabetes Podiatry 153
5.2.2 Why are Specialist Titles Problematic? 154
5.3 The Effects of Titles 155 5.3.1 The Effects on Clinical Activities and Access to Services 155
5.3.2 Effects of Title on how the Title-Holder is Perceived 157 5.3.3 The Legal Implications of Title 158
5.3.4 Effects of Title on Other Clinician’s Perceptions 159 5.3.5 The Effects of Title on Patient’s Perceptions 160
5.3.6 The use of Academic Titles 161 5.3.7 Alternatives to the Current Variety of Titles 162
5.4 So what? What IS in a Name? 164
6.0 SPECIALISATION IN DIABETES PODIATRY 167
6.1 Variation 167
6.2 Stratification 168
6.2.1 A Divided Specialty 169
6.3 Immersion in the Specialist Role 169 6.3.1 Education 170
6.3.2 Clinical Roles and Activities 171
vii
6.3.3 Case Management Roles and Activities 174
6.3.4 Leadership of Services 177
6.4 Part-Time Specialisation 178 6.4.1 Community Podiatrists 179
6.5 Focussed Diabetes Specialty or Multi-Specialists? Differing Perspectives 180
6.6 Implications of Specialisation in Diabetes Podiatry 185
6.7 The Current Status of Diabetes Podiatry 186
7.0 Results - Documentary Analysis 189
7.1 Descriptors and Titles 189
7.2 Specialist Areas 192 7.3 Grading and Banding 192
7.4 Specialist Posts with Diabetes Component 197 7.5 Discussion – Documentary Analysis 197
8.0 Summative Discussion 201
8.1 Quality of the Research 203
9.0 Conclusions 205
9.1 Limitations of the Study and Future Directions 205
9.2 A Personal Reflection 207
References 209
Appendices 235
viii
List of tables, graphs and illustrations:
Table 1. Kanton et al (2001) Stepped care model p5
Table 2. Pathway from initial qualification to consultant diabetologist p10
Table 3. Competence for GPwSIDs p11
Table 4. Foot in Diabetes UK Constitution and aims p22
Table 5. Diabetes specialist podiatry assistant - main team role p25
Table 6. Preconditions for specialist practice in diabetes p28
Table 7. Characteristics of specialist practice in diabetes; Ways of working p30
Table 8. Characteristics of specialist practice in diabetes; Services provided p32
Table 9. Characteristics of specialist practice in diabetes; Assessment p33
Table 10. Characteristics of specialist practice in diabetes; Management p34
Table 11. Characteristics of specialist practice in diabetes; Educational output p36
Table 12. Characteristics of specialist practice in diabetes; Service and policy p37
Table 13. Professional outcomes & consequences of specialist practice in diabetes p38
Table 14. Clinical outcomes and consequences of specialist practice in diabetes p40
Table 15. Bucher’s (1988) stages in development of specialist practice p50
Table 16. Weber’s three pure types of authority p72
Figure 1. Methodological Overview p77
Table 17. Norris’ (1982) model of concept clarification p81
Table 18. Chinn and Jacobs’ (1983) model of concept clarification p82
Table 19. Chinn and Kramer’s (1995) model of concept clarification p82
Table 20. Walker and Avant’s (1988) model of concept analysis p83
Table 21. Stages in Rogers’ (1993) model of conceptual analysis p85
Table 22. Morse’s principles of assessing pragmatic utility p86
Figure 2. Interviews p111
ix
Table 23. Advertising of Specialist Posts 1945-2010 p190
Figure 3. Advertising of Specialist Posts – changes over time p191
Table 24. Advertised Specialist Areas 1945-2010 p193
Figure 4. Advertised Specialist Areas 1945-2010 p194
Table 25. Advertised Specialist Posts by Grade 1976 Onwards p195
Table 26. Advertised Specialist Posts by Band 2005-2010 p196
Figure 5. Advertised Posts with Possible Diabetes Component p197
x
Academic Thesis: Declaration of Authorship
I, Dawn Bacon declare that this thesis and the work presented in it are my own and has been
generated by me as the result of my own original research.
Podiatry and Diabetes: An Exploration in Specialisation
I confirm that:
1. This work was done wholly or mainly while in candidature for a research degree at this
University;
2. Where any part of this thesis has previously been submitted for a degree or any other
qualification at this University or any other institution, this has been clearly stated;
3. Where I have consulted the published work of others, this is always clearly attributed;
4. Where I have quoted from the work of others, the source is always given. With the
exception of such quotations, this thesis is entirely my own work;
5. I have acknowledged all main sources of help;
6. Where the thesis is based on work done by myself jointly with others, I have made clear
exactly what was done by others and what I have contributed myself;
7. Either none of this work has been published before submission, or parts of this work have
been published as: [please list references below]:
Signed: ………………………………………………………………………………………………………
Date: ……………………………………………………………………………………………………….
xi
Acknowledgements
My sincere thanks go to my two supervisors, for without their support I could not have
even begun this journey. I thank Dr Alan Borthwick for his help, patience, words of
wisdom and extensive knowledge in the field of professional issues. I thank Dr Julia
Potter for originally introducing me to the world of research, for her encouragement
and wonderful organisational skills. I also thank the University of Southampton and
the panel who interviewed me for the award of the Richard Newitt Bursary, which
made this undertaking financially possible.
I would also like to thank the research participants, all extremely busy people who
gave most generously of their time during what were in-depth interviews – several key
actors commented on a sensation of exhaustion at the end of the session!
I also thank my friends and colleagues within the research community, in the NHS and
in private practice. They have been interested and supportive at all stages of this
journey.
Lastly, but far from least, I thank my husband Clive and our son Tim. Our lives have
changed significantly during the course of my research journey, but no matter how
hectic or stressful their lives have been they have remained supportive and did not
doubt that I would complete this work.
Without any of these people I would not have been able to complete this marathon and
I give them my heartfelt thanks.
1
1.0 LITERATURE REVIEW
1.1 Introduction to the Literature Review
In a departure from the norm in podiatric research, a concept analysis (allied to the
literature review) has been undertaken. Reflecting the interrelated nature of
reviewing the literature and analysis of a concept (a process of interrogating the
literature, approaching it as data) the literature review and concept analysis are
presented concurrently. This method of presentation avoids duplication which would
otherwise be inevitable. The concept analysis is presented first (section1.1.1) as the
author seeks to provide an overview of the concept of specialisation. Having
addressed the concept of specialisation, the maturity of the concept of diabetes
specialist podiatry is assessed. Within section 1.7 the literature review explores
theoretical perspectives associated with specialisation. Finally consideration of
medical dominance and authority and how they impact upon the profession of
podiatry conclude the literature review in section 1.8.
1.1.1 Concept Analysis
The aims of this concept analysis were to explore the concept of specialisation and
to assess the maturity of the concept of diabetes specialist podiatry. The analysis
begins with an overview of the concept of specialisation, the everyday and scientific
uses of “specialist” and “specialisation” are considered as are the setting and context
of specialist activity. The comparable cases of medicine and diabetology (medical
specialisation in diabetes practice), nursing and diabetes specialist nursing are also
examined. These cases are compared with the case of podiatry and diabetes
specialist podiatry.
To evaluate the maturity (or clarity of the scientific concept) of diabetes specialist
podiatry its preconditions, characteristics, outcomes and consequences are explored
and compared with the preconditions, characteristics, outcomes and consequences of
both nursing and medical specialisation in diabetes. This information is presented in
section 6.1, using comparative conceptual maturity matrices (tables 6-14).
1.1.2 The Concept of Specialisation
Historically “specialist” and “specialisation” are derived from the word “special” the
meaning of which dating from circa 1225 was "better than ordinary" or from circa
2
1303 “marked off from others by some distinguishing quality” (Harper 2008). The
sense of “special” indicating engagement “in a special study or line of business"
was first attested in 1881. While “specialization1” is recorded from 1843,
“specialist” is first attested in 1856 – originally in the medical sense (Harper 2008).
Contemporary uses of the word specialist include that of a noun meaning “a person
who is highly skilled or knowledgeable in a particular field”, or an adjective,
meaning “relating to or involving detailed knowledge or a specific focus within a
field” (Compact Oxford English Dictionary 2008).
In evolution and economics specialisation has historically been assigned meanings
in terms of adaptation to the environment and natural selection (Darwin 2003), or
the division of labour which can maximise production (Smith 1789). Theodorson
and Theodorson (1970, p408) defined specialisation as:
“The division of labour or territorial areas of a group, community or society
into a number of interrelated and specialized functions. Occupational specialization and ecological specialization are types of specialization”.
Competing theoretical perspectives point to workforce specialisation as a
phenomenon which encourages individuality (Durkheim’s 1964 evolutionary theory
of professions) or, within the Marxist tradition one which dis-empowers workers
(especially professionals who have enjoyed relative autonomy) through the process
of proletarianisation (Oppenheimer 1973, McKinlay and Stoeckle 1988).
Within contemporary economics, the economist Simon Domberger (1998, p78)
considers that specialisation at the organisational level is seen to “fragment
monolithic corporations and public sector behemoths into smaller, more focussed
constituent parts”. Domberger (1998) discusses specialisation in the public and
private sector, within the context of operational boundary changes and outsourcing
(purchasing goods or services from specialised suppliers). These facets have
resonance with current patterns in healthcare – both in terms of boundary re-design
and the purchase of services – for example purchasing the services of a diabetes
specialist podiatrist. Domberger argues that this form of purchasing is mutually
1 British texts usually refer to specialisation; however the alternative spelling specialization is also
used. The author has used the British spelling within her writing, but where quotes are made the original spelling has been retained.
3
beneficial for the organisation and the specialist providing the service. The former
is allowed to narrow the range of its internal production activities while the latter
gains a new client, increases their share of the market and thus extends the degree of
specialisation on the supply side of the market. Economy of scale results from the
reduced cost of investment in training for a comparatively small number of
specialists as opposed to the relatively high costs involved in training many people –
while for healthcare practitioners for whom continual professional development is a
requirement, there will be on-going training costs – the specialist does not have to
invest in complete new training for each new customer.
Related to the notion of the specialist, are “expert” and “consultant”. Definitions of
“experts” and “consultants” have been proposed (Evers and Menkhoff 2002), which
highlight the centrality of knowledge and the “knowledge economy”
“An expert has obtained knowledge. He is a professional knowledge broker, a middleman between knowledge producers and knowledge users.”
“A consultant is an expert, who acquires packages and sells specific and
confidential knowledge for a fee with the expectation that his knowledge is applied and his advice is acted upon.”
Specialisation is by nature divisive (Domberger 1998, Freidson 1988), erecting
barriers between those who have gained the required complex technical skills and
specialist knowledge and those who have not. Within professional groups such as
lawyers and doctors it is considered to confer monopolistic advantages to those
groups (Domberger 1998, Freidson 1988).
1.2 Specialisation in the Context of Healthcare
Within healthcare, Nancarrow and Borthwick (2005) highlight that the concept of
specialisation remains both poorly defined and under-debated in the literature; also
making a distinction between specialisation – which occurs within a profession, and
substitution – which occurs across disciplinary boundaries. The lack of a clear
definition of specialisation is also noted by Grilli et al (1999), while Leicht and
Fennell (2001) point to the paucity of research which asks professionals from
different backgrounds, working in different organisational contexts, what they view
as the nature of their professional role or how they view their professional roles.
4
Within the context of healthcare (using the example of neurosurgeons), Murphy
(1990, p73) describes:
“…the specialisation of professionals in deepening niches of abstract utilitarian knowledge.”
He contrasts this with the specialisation of the proletariat in different segments of
routine unskilled labour; the former to a very large extent retaining control over their
work, while the latter become de-skilled and dis-empowered. Proletarianisation of
the healthcare workforce is also rejected by Freidson (1988) and Elston (1991) who
point to extensive criticisms of a thesis of proletarianisation as applied to healthcare
professions and specifically medicine, concluding that theories of diminishing
medical power are not satisfactorily developed or amenable to rigorous testing (see
also section 1.8 medical dominance).
In healthcare settings Strauss et al (1963, p151) argue that:
“…the division of labour is a complex concept, and at hospitals must be seen in relation to the professionalized milieu”.
Further, Freidson (1988, xii) speaks of the:
“…system-supported differentiation within professions”
and of how the credential system works to establish positions for ordinary practising
professionals and other strata within the same profession. Bennett and Grant (2004)
point to specialised knowledge as the product of long, intensive academic
preparation. They consider this to be the hallmark of a profession, signalling the
maturity of physiotherapy and confirming its status as a profession as opposed to an
industry (Bennett and Grant 2004).
Kanton et al (2001) developed a model of “stepped care” (table 1.) in which the
function of the “specialist” is clearly defined:
“Specialists provide consultation services to primary care physicians in managing more-complex cases, supervision of nurse or case managers,
“collaborative care” or co-management for patients in the primary care clinic not responding to initial primary care-based treatment and on-going
specialty care for the most severe or complicated cases” (Kanton et al 2001).
5
Table 1. Kanton et al (2001) Stepped care model.
Step care
levels
Type of problem Healthcare practitioner roles
Level 1
Preventative services and diagnosis of
subclinical disorders.
Primary care physician provides screening, diagnosis, preventative services and patient education and monitors
outcomes.
Level
2
A newly diagnosed
disorder or relapse or exacerbation of
chronic disorder
Primary care physician provides diagnosis and
prescription of medication and recommends lifestyle changes. Allied professional helps with increasing
frequency of contact, monitoring symptoms and side effects, support for self-management activities (i.e.
exercise, diet change, checking blood glucose) and
referral back to primary care doctor for adverse outcomes. Specialist supervises caseload of allied health
professional.
Level 3
Patients with adverse outcomes in level 2
care
Specialist consults with patient and primary care physician and recommends changes in medication and/or
lifestyle alterations; specialists may provide several
visits, preferably within primary care.
Level 4
Patients with adverse outcomes in level 3
care
Specialist takes over care for patients with adverse outcomes despite level 3 care or those with higher initial
level of complexity.
Summarised from: Kanton, W., von Korff, M., Lin, E. and Simon, G. (2001) Rethinking practitioner roles in chronic illness: the specialist, primary care
physician, and the practice nurse. Gen Hosp Psychiatry, 23:138-44.
While the Kanton et al model applies the term specialist to doctors, Gask (2005)
highlights that for some conditions it could also mean a non-medical specialist.
1.3 Related Case: Medical Specialisation
Specialisation of medical function has existed since primitive times (Rosen 1944).
Weisz (2003) documented the emergence of medical specialisation in the nineteenth
century London. In concordance with Rosen (1944), Weisz (2003) argues that the
desire to expand medical knowledge through research and the increased bureaucratic
efficiency associated with classifying patients into groups, were important drivers
for medical specialisation. Brain (1953) also linked the evolution of medicine to a
process of differentiation intimately related to increasing knowledge and Cohen
(1960) considered that advancing knowledge led inevitably to specialisation in all
fields. While Brain (1953), Cohen (1960) and Godber (1978, 1961) considered that
specialisation was an inevitable and necessary condition of progress in medicine,
Weisz (2003) and Rosen 1944) both consider such overdetermination (apparent
inevitability) of medical specialisation to be an incomplete explanation - though they
6
maintain that a transformation of intellectual perspective involving the production
and dissemination of knowledge was the starting point for the specialisation process.
Rosen (1944, p6) describes medical specialisation as:
“…a process of differentiation within a definite realm of social activity with
a distinctive inner order of its own”
The Foucauldian analysis of the birth of medicine highlights the social, historical
and economic conditions required for the construction of an “independent field”
(Fournier 2000). Foucault (2003) emphasised the advent of scientific medicine,
which based upon anatomy and pathology allowed the development of localised
pathology (conceptualisation of diseases relating to specific organs, tissues and body
sites). Rosen (1944) considers that this concept of localised pathology permitted the
cultivation of foci of specific interest. Further, Armstrong (1997, p173) points to the
“…struggle to combat disease that elicits an organised response, that in its
turn coalesces into a formal discipline”
and Strong (1984) highlights the links between “scientific medicine” and the division
of medical and scientific labour, leading to the new “research-based approach” to
medicine.
Stevens (1966) points to the forces which supported and maintained generalist
approaches to medicine which prevailed during the nineteenth century, highlighting
the advent of the specialist hospital movement in England and Wales as the way in
which centres of specialist teaching and research were established despite the
hostility of the older generation of physicians. Weisz (1997) in focussing on the
history of ways in which medical specialisation has been represented and classified
documents that medical specialists practised in small numbers during the first half of
the nineteenth century; it was only from 1865 or so that specialisation emerged as a
widespread phenomenon and specialists became a recognisable social category.
Though separated by approximately one hundred years, there exist certain parallels
between the early emergence of medical and podiatric specialisation; initially claims
to specialist status lacking educational underpinnings, followed by a pattern of
establishing foci of interest, special interest groups, standards of practice – and
currently within podiatry attempts to establish accredited educational and career
pathways (see section 5). Weisz (2003) notes that during the last three decades of
7
the century, specialist journals, societies, professorships, and hospital positions all
emerged and some medical practitioners began referring to themselves as specialists.
The conditions of specialist medical practice remained very fluid for more than half
a century; anyone could call himself or herself a specialist of virtually any sort, as is
currently the case in podiatric specialisation. During the latter part of the nineteenth
century it was argued by some that membership of a specialist society, possession of
a specialist post, exclusive practice in a given specialty, or mandatory certification
and examinations should be demanded of those claiming medical specialist status
(Weisz 2003). However, within medicine, for many decades simply calling oneself a
specialist was as valid a criterion as any for determining specialist status. The
organisation of medical societies developed in the last twenty five years of the
nineteenth century was a key step in the consolidation of medical specialisation
forming the basis for the specialist sections of the then new Royal Society of
Medicine (Stevens 1966). At this time medical directories constituted a potential
and particularly visible location for making claims to specialism. However the
emerging specialties experienced difficulties in terms of inclusion of their specialist
claims and credentials in medical directories, which Weisz (1997) considers:
“…undoubtedly reflected real professional opposition to the formal recognition of specialization. British directories found themselves
confronted by the hostility of the British Medical Association to any overt recognition of specialization that would permit patients to bypass GPs and
the referral system”.
Such tensions between General Practitioners (GPs) and the hospital based physicians
and surgeons, focussed around competition for patients, led to the initially informal
system where GPs could refer patients to specialised colleagues for a second
opinion, while still maintaining a continuing relationship with the patient (Stevens
1966).
During the interwar years while some medical practitioners accumulated a variety of
hospital posts, suggesting that specialist appointments had not yet become the
preserve of committed specialists, other individuals developed a consistent profile of
diplomas, posts, and society memberships that signify a career-long specialism
(Weisz 1997). This would seem to corroborate the view that medical specialisation
was rather weakly developed in Britain until after World War II (Weisz 1997).
Indeed Godber (1978) and Stevens (1966) point to the effects of the Second World
8
War in promoting the development of pathology and radiology, and the impact of
the Armed Forces in helping the emergence of specialised practice in neurosurgery,
thoracic and plastic surgery. The phenomenon of generalist practitioners
undertaking part time specialist roles was also to be found in medicine between the
wars. Weisz (1997) notes that GPs were permitted to claim specialist status as
anaesthetists, surmising that the hospitals had not yet established consultant posts in
the field, thus leaving anaesthetics open to GPs. In 1935 a diploma in anaesthetics
was developed for GPs, prior to this anaesthetics had been considered to be of low-
status (Stevens 1966). The time between 1950 and 1975 saw a threefold increase in
the numbers of formal specialist anaesthetists (Godber 1978), with consultant
anaesthetists becoming one of the largest specialist groups in medicine by 1978.
Thus, between the period of 1935 and 1978 anaesthetics was transformed from an
area considered to be of low-status where generalist, community based practitioners
acting as part time specialists were active and accepted, into one of the largest
groups of specialist medical consultants. Despite the extraordinary fragmentation
of medicine into different specialties, Strong (1984) highlights that the profession
has maintained a separate community with a solitary and isolated way of life which
normally overrides internal divisions of labour.
The report of the working group on specialist medical training, chaired by the then
Chief Medical Officer Kenneth Calman, was published in Spring 1993 (HMSO
1993). The review stemmed from the European Commissions’ concerns that the
system in the UK for the mutual recognition of specialist medical qualifications
among EEC members did not comply with the 1975 directives (Meadows 1996).
The government accepted the recommendations in full; the report brought major
changes to medical specialist’s training which were phased in from December 1995
(Calman 1995):
A reduction in the time doctors spent in specialist training from an average of
twelve years to an average minimum of seven years (Meadows 1996).
Training became more structured, managed, supervised and assessed
(Meadows 1996), with formalised curricula stipulating the required
competencies and experience trainees were expected to acquire and the
9
duration, entry and assessment requirements of specialist training (Calman
1995).
The former apprenticeship style training which incorporated three training
grades was replaced in April 1996 by two training grades for the period of
specialist training (Calman 1995):
1. Senior House Officer, for a period of general professional and basic
specialist training.
2. A second training grade of Specialist Registrar, encompassing the
former Registrar and Senior Registrar grades, providing higher
specialist training.
The National Training Number (NTR) was introduced for all Specialist
Registrars, as a means of managing their progress and as their “passport to
training” (Calman 1995).
The Certificate of Completion of Specialist Training (CCST) was introduced,
which allowed the doctor’s name to be included in the new specialist
register, maintained and published from 1996 by the General Medical
Council (GMC) (Calman 1995). The CCST clearly marked the defined end
point of specialist training, indicating that a doctor has completed training to
a standard compatible with independent practice and is therefore eligible for
consideration for a consultant appointment (Meadows 1996). Though
Calman (1995) stresses that it is inclusion on the specialist register (rather
than the award of a CCST) which makes the doctor eligible for appointment
at consultant level and indeed that from 1997 inclusion in the specialist
register was to become a legal requirement for NHS consultants. The impact
of this was to allow doctors who, under the former system, would remain in
senior registrar posts for several years, to apply for consultant posts
(Meadows 1996).
The ratio of consultants to doctors in training was changed. Consultants’
commitment to training, supervising and assessing trainees was increased.
1.3.1 Diabetology (medical specialisation in diabetes)
Within the field of diabetes care the route to medical specialisation is clearly defined
with a formal pathway for career progression to consultant level.
10
Table 2. Pathway from initial qualification to consultant diabetologist
1. Initial graduation and registration with the GMC. 2. Two years of general professional training in an approved Senior House Officer post.
3. Membership of the Royal College of Physicians. 4. Obtain a post with a national training number as a specialist registrar in diabetology and
endocrinology (four years further training). Some doctors achieve an MSc during this
phase. 5. Certificate of completion of specialist training in diabetology and endocrinology awarded
for successful completion of a recognised specialist registrar training scheme, run by the
Specialist Training Agency.
6. Entry to the GMC specialist register and eligibility for consultant diabetologist post.
Summarised from Health Career Net http://www.healthcareernet.co.uk/Physician/CareerProfiles/PID00179.aspx (accessed
13.11.06)
In considering the impact of the Government led transfer of chronic disease
management from secondary to primary care, Greenwood (2005) points out the
“downsizing" of some specialist units by local primary care trusts, increasing
frustration and discontent among diabetologists, declining recruitment into the
specialty and unfilled consultant posts. Further Greenwood (2005) raises concerns
about the viability of integrated care, concluding that without diabetologists and their
multidisciplinary teams, general practitioners will be left unsupported and access to
specialists for patients with complicated, diabetes related problems will
be reduced.
1.3.2 General practitioners with special Interest in Diabetes (GPwSID)
In 2000 the NHS Plan described a new role for general practitioners with a special
interest (Department of Health 2000). Against a background of the growing burden
of diabetes care in Britain, health policy has driven the increasing the role of general
practitioners with special interest in diabetes (GPwSID). Practice Based
Commissioning, the National Service Framework for Diabetes and Payment by
Results have all played a role in developing and extending “shared care” or “stepped
care” models of service provision in diabetes.
Education for GPwSIDs is less formalised than that of diabetologists. Competence is
considered to be achievable by following the steps outlined in (table3.):
11
Table 3. Competence for GPwSIDs
Gaining experience of working under direct supervision of a consultant
physician with special interest in diabetes in a hospital or community setting.
The preparation of a personal development portfolio showing evidence of
advanced clinical skills and knowledge including input/education from
professionals from other disciplines, e.g. podiatrists, dieticians, psychologists etc.
Evidence of attendance at relevant courses, self-directed learning or other means to meet learning gaps identified through the Professional
Development Plan and annual appraisal.
Summarised from “Guidelines for the appointment of general practitioners with special interests in the delivery of clinical services: diabetes” http://www.natpact.nhs.uk/uploads/PDF%20Diabetes.pdf (accessed 03.10.08).
In outlining the service provided by Practitioners with Special Interest (PwSI) which
includes GPs, Dentists, Optometrists and Pharmacists, a suite of documents
published by the Department of Health in 2007 (Department of Health 2007a, b and
c) places a duty on the commissioners of care to:
“…ensure that the same quality and service standards apply to all NHS
specialist care delivered in community settings, whether that care is provided by accredited PwSIs or by NHS specialist staff.” (Department of Health
2007a, p5).
A broad role-definition for PwSI was offered in document two:
“The role of the PwSI is not a generic one in the way that the role of a primary care GP, community pharmacist, nurse or a hospital consultant
is. PwSIs are appointed to deliver a particular clinical service within a defined patient pathway…” (Department of Health 2007b, p6).
Document 3 offered a formal definition of the role of GPwSI and Pharmacist with
Special Interest (PwSI):
“A GP or a Pharmacist with a Special Interest supplement their core generalist role by delivering an additional high quality service to meet the
needs of patients. Working principally in the community, they deliver a clinical service beyond the scope of their core professional role or may
undertake advanced interventions not normally undertaken by their peers. They will have demonstrated appropriate skills and competencies to deliver
those services without direct supervision.” (Department of Health 2007c, p4).
Evidence required for accreditation as a GPwSI (which may be presented in
portfolio format) includes:
Evidence of current registration
12
A portfolio of evidence to demonstrate appropriate education, motivation,
training and development
All relevant certificates to be submitted with the application
How appraisal and personal development planning will be realigned to take
account of their new role
How core role will be protected as they take on the new role
Audits of core role and outcomes for practice development
Summary of the supervised clinical work that they have completed, and
participation in appropriate local clinical networks, where this exists
For GPwSIs inclusion on the generalist register of the GMC and on a PCT performers list
Evidence that the applicant meets the requirements of any specialty specific guidance, where they exist
A detailed reference from an appropriate specialist that confirms that the applicant is competent to take on the new role
(Department of Health 2007c, p11).
At the heart of the accreditation process is the notion of competence, GPwSIs must:
“Demonstrate appropriate levels of skill and competence to fulfil the role described” (Department of Health 2007c, p7).
There are concerns about the move from secondary to primary care including: the
motives for such a move which some consider to be more about containing costs
than attempting to improve global patient care (Kenny 2005), the adequacy of
training for GPwSID, the provision of diabetes care by practice nurses rather than
the GPwSID and the lack of medical input into nurse consultant’s contracts of
employment (Wroe 2002).
1.4. Related Case: Nurse Specialisation
“[Nurse] specialists are experts in a particular area or about the needs of a
specific client group, with advanced education and a research base firmly rooted in nursing” (Humphris 1994).
Nursing posts involving higher levels of practice arose from three types of initiative
(Walters 2000): nurse specialist developments, nurse practitioner developments and
role expansion in response to the Scope of Professional Practice published by the
United Kingdom Central Council for Nursing, Midwifery and Health Visiting
(UKCC) in 1992 and the New Deal for Junior Doctors, published in the same year
(NHS Management Executive 1992).
13
The clinical nurse specialist role in areas such as infection control and tissue
viability has existed informally since the 1970s (Humphris et al 1999, Nursing and
Midwifery Council [NMC] 2005). The title was not regulated and post holders
usually achieved such jobs through extensive experience and appropriate post-
registration courses. Clinical nurse specialists were usually managed within the
nursing service (NMC 2005).
Nurse practitioners developed first in primary care in the late 1980s (NMC 2005)
offering an alternative service to that provided by general practitioners and filling
gaps in service provision. Nurse practitioners diagnose, refer, prescribe and provide
complete episodes of care for clients with undifferentiated health problems. The
NMC (2005) describe how in the 1990s, posts emerged in secondary care with the
titles of nurse practitioner, advanced practitioner and advanced nurse practitioner.
Such posts frequently involved nurses giving care or performing tasks previously
undertaken by medical doctors (NMC 2005), practitioner posts being more closely
linked to medical practice and the adoption of medical tasks as opposed to higher
levels of “nursing” (Walters 2000).
The beginning of a formalisation process for titles and career progression can be
traced to the 1994 report of the Post-Registration Education and Practice (PREP)
project and the UKCC’s 1998 proposals for the regulation of a higher level of
practice (NMC 2005). The PREP project identified two levels of practice beyond
the point of registration; “advanced” and “specialist”. Explicit standards, in the form
of learning outcomes, were set for specialist practice and a conceptual descriptor of
advanced practice was offered. The NMC (2001) drew a clear distinction between
practising within a speciality and holding the recordable qualification of specialist
practitioner. In order to become a specialist practitioner the nurse must have
completed a programme of preparation that is: at least first degree level, no less than
an academic year in length and made up of 50% theory and 50% practice. Latterly,
consultant nurse, midwife and health visitor posts have been introduced in the NHS
(NMC 2005): consultant nurses, midwives and health visitors are expected to be
competent to initiate and lead significant practice, education and service
development. Consultant nurses, midwives and health visitors are to have been
14
educated to masters or doctoral level, be registered as a nurse, midwife or health
visitor, and hold additional professional qualifications (NMC 2005).
Whether the specialist nurse is more advanced than the generalist nurse remains
unclear. Pearson and Peels (2002) consider that there is broad agreement that the
advanced practitioner possesses expertise and competence at a level higher than the
professional nurse or the nurse specialist and that this is acquired through extensive
experience and advanced education. Confusion is compounded by the array of titles
currently in use. These include (Longley et al 2004): nurse practitioner, nurse
clinician, specialist nurse, highly specialist nurse, diabetes specialist nurse, stroke
nurse, tissue viability nurse, clinical nurse specialist (infection control), consultant
nurse, specialist nurse practitioner, advanced nurse practitioner, enhanced nurse
practitioner, senior clinical nurse, behavioural psychotherapy nurse, clinical nurse
facilitator and nurse co-ordinator. Differences in title have been attributed to
preference (Walters 2000), rather than any attempt to describe the post based on role
content. Wilensky (1964) noted that changing professional titles, discarding those
associated with low status and replacing them with alternatives could be seen as a
strategy to link new titles with higher status.
1.4.1 Diabetes Specialist Nurses
MacKinnon (2002) highlights the employment of nurses in diabetes care in the home
setting before the discovery of insulin in 1921. The first diabetes specialist health
visitor was appointed in 1950 (MacKinnon 2002, Baksi 1995) by Dr Joan Walker in
Leicester, laying the foundations for subsequent diabetes nurse specialist posts
(Baksi 1995). Specialist nurse posts in diabetes arose out of an appreciation that
some patients had specific needs that were not being met by existing medical and
nursing staff (Walters 2000), spurred on by the advent of new more dilute forms of
insulin suitable for patient self-administration (MacKinnon 2002). Clinical nurse
specialists in diabetes have come to be known as “diabetes nurse specialists”
(Humphris et al 1999); the advent of U100 insulin during the 1980s seeing a
significant expansion in diabetes nurse specialist numbers, linked to the need for
patient education in order to safely self-manage the new insulin regimes (Lucas and
Walker 2004, Da Costa 2000). This expansion was generally locally driven and
15
piecemeal in nature (Wroe 2002) and subsequently diabetes nurse specialist roles
developed with little guidance and support (Da Costa 2000).
The most recent data located concerning educational preparation of existing diabetes
specialist nurses, is the 2003 national survey of 653 diabetes specialist nurses
(Liahana et al 2003). Of the 334 respondents, the majority (69%) had undertaken
the (no longer extant) English National Board 928 Course in Diabetes Nursing Care
(ENB 928), with 14% holding a BA or BSc (Hons) in specialist practice. Only 290
respondents answered the question “what is your highest qualification in nursing”;
of these 24% held a diploma, 39% a bachelor’s degree, 6% a postgraduate diploma,
22% a master’s degree and 1% a doctorate. These qualifications were not
necessarily within the specialty of diabetes nursing. The first formal English course
in diabetes nursing was established at Birmingham General Hospital in 1978
(MacKinnon 2002), this later became the ENB 928. Liahana et al (2003) consider
the ENB 928 (or a similar course) to be essential for newly appointed diabetes nurse
specialists. However Crowley (2000) highlights the variable curricula and duration
of the now no longer extant ENB 928 (which should have taken 20 days and
included clinical visits), and the current inadequacy of educational programmes in
preparing diabetes nurse specialists appropriately for the requirements of their
multifaceted role.
The British Diabetic Association (BDA, later to become Diabetes UK) Directory of
UK Specialist Nurses in Diabetes was originally devised in 1986 through a joint
Royal College of Nursing/BDA initiative. Registration is voluntary and is updated
annually, appearance on the register is perceived by most diabetes nurse specialists
to be of value (Humphris et al 1999). In 2000 there were 1044 diabetes specialist
nurses listed in the Diabetes UK Diabetes Specialist Nurse Directory, with some 126
different titles assigned to them (MacKinnon 2002). The only official document
guiding the role of these nurses has been the 1991 Royal College of Nursing
guidance document, before and since that time the nurses have defined their own
roles (MacKinnon 2002). The lack of a nationally recognised infrastructure to
support the development of specialist practice raises concerns over roles,
responsibilities, accountability and liability (Walters 2000) which despite repeated
16
attempts aimed at providing a career and competency framework (Hicks 1999a,
Tipson and Turner 2002) persists today.
1.5 Podiatric Specialisation
Historically podiatry has held (Lorimer 1995) and been successful in defending
(Page and Dagnall 1992) the right to diagnose and treat pathological conditions
relating to the foot without medical referral. Contrastingly, Hugman (1991)
highlights that the right to practise independently, to diagnose and prescribe
treatment is a comparatively new issue in nursing, as medicine has long been
successful in keeping these issues off the public agenda. Degree courses for podiatry
were established in the early 1990s, (Lorimer 1995), and unlike nursing, the current
minimum entry level qualification for podiatry is at graduate level. Despite these
factors and its long history (Page and Dagnall 1992), since the beginning of the
twentieth century, podiatry has struggled to win a valued place in the provision of
modern health care (Larkin 1983). The perception amongst podiatrists can be that
other professions consider podiatrists to have low status (Vernon et al 2005).
Medical and nursing professions were considered not only to hold this view, but also
to communicate it to the general public (Vernon et al 2005) and within the UK
Young (2003b) considers that podiatry has not been afforded the status it deserves.
Vernon and Borthwick (2006) point to the drive for specialisation and the “virtuoso
role” coupled with attempts to shed less glamorous work. Indeed podiatric
specialisation in a specific area such as diabetes (Vernon et al 2005), or podiatric
surgery (Mandy 2008) as opposed to practice in routine work has been linked to
increased status, however echoing Weber (2005), Mandy (2008) points out that
increased status is not necessarily related to increased remuneration.
Early references to specialised practice in chiropody2 are sparse. However before the
inception of the NHS Lorimer (1995) highlights the value of chiropodists in
orthopaedics and diabetes, while Dagnall (1962) points to child health and
orthopaedics as specialist fields. More recently Borthwick (1999, 2000) has detailed
2 Podiatry is now common nomenclature for what was previously known as chiropody. Practitioners
in the United States officially adopted podiatry as the name of their profession in 1958 - considering
that it described the study and treatment of the foot and avoided confusion with chiropractic. In the UK, the Society of Chiropodists added the term 'Podiatrist' to their name in 1993, to become the
Society of Chiropodists and Podiatrists.
17
the evolution of podiatric surgery. The comprehensive review of the podiatry
workforce in Northern Ireland (Project Group 2002) highlighted a need for the
creation of clinical specialist posts, providing the opportunity for career progression
along a clinical route; one focus group respondent observing that “You’re clinically
dead after Senior I.” The review identified potential clinical specialist roles in
wound care, biomechanics, podopaediatrics, falls prevention, rapid response,
rheumatology, vascular, A&E and nail surgery (Project Group 2002).
1.5.1 Prescribing
While for appropriately qualified pharmacists and nurses independent prescribing
has been established (Department of Health 2006), only limited forms of prescribing
or access to prescription only medicines are currently available to podiatrists.
Supplementary prescribing which was extended to podiatrists in 2005 (Stuart et al
2010), allows practitioners to prescribe medicines within their scope of practice to
identified patients (Department of Health 2005b). It is however a constrained and
inflexible form of prescribing; for each individual patient a Clinical Management
Plan (CMP) must be signed by an independent prescriber (Department of Health
2005b), who is usually a physician (Stuart et al 2010). In August 2010, 114 Society
of Chiropodists and Podiatrists members were supplementary prescribers (Society of
Chiropodists and Podiatrists 2010). An alternative form of access to prescription
only medicines utilised by podiatrists is that governed by patient group directives
(PGDs). This allows named practitioners to access (supply or administer, not
prescribe) medicines for any patient within a defined group (Department of Health
2005b). Such supply and or administration of medicines is also constrained, being
protocol led with restrictions imposed by both local pharmacy and medical protocols
(Society of Chiropodists and Podiatrists 2010).
1.5.2 Special Interest Groups
The Society of Chiropodists and Podiatrists web site contains sections for special
interest groups, including: The Podiatric Biomechanics Group, Podiatry Rheumatic
Care Association, Lower Limb in Dermatology, Foot in Diabetes, Hospital
Podiatrist’s Panel, PodoPaediatrics, the Foot Health Trade Association, the
Committee for Private Practice, Therapeutic Footwear, Skills for Health, Forensic
Podiatry and Homeopathic Specialists’ Group, the Faculty of Surgery and the
18
Faculty of Management. Thus of the clinical (as opposed to managerial) specialist
areas, podiatric surgery alone enjoys faculty status, though a Faculty of Podiatric
Medicine is also extant. Uniquely amongst podiatrists, podiatric surgeons could be
employed by trusts under lucrative MC21 (medical consultant grade) contracts,
though the Agenda for Change banding structure has now superseded this.
1.5.3 The Establishment of Podiatric Surgery
The origins of podiatric surgery were characterised by the activities of a small group
of podiatrists challenging the jurisdiction of medically qualified surgeons - and the
ensuing boundary disputes and inter-professional conflict (Borthwick 1999, 2000).
During the 1970s, faced with increasing numbers of members taking unapproved
courses in local anaesthesia, the then Society of Chiropodists campaigned for and
secured state approval in local anaesthesia techniques (Lorimer 1995, Borthwick
2000). Legitimate and accepted access to local anaesthesia in 1972 allowed
podiatrists to encroach upon the boundaries of the medical profession and using
phenolisation techniques imported from America, to establish and practice nail
surgery (Lorimer 1995), which had hitherto been the domain of orthopaedic
surgeons. The medical profession retained the right to oversee training in local
anaesthesia with guarantees intended to prevent use of local anaesthesia for surgical
practice a condition of state approval (Borthwick 1999). However these guarantees
were ambiguously worded and combined with the open nature of the scope of
practice set out by the Chiropodists Board, provided an opportunity for a small
group of podiatrists working in the private sector to extend their scope of practice
and in effect begin to compete with orthopaedic surgeons for the provision of
invasive foot surgery (Borthwick 2000). The medical establishment opposed
surgical procedures being undertaken by any non-medically trained practitioners and
in 1980 The Royal College of Surgeons (RCS) of England sought to limit the
“intrusion of podiatrists into areas of surgery”, citing that for reasons of “patient
safety” chiropodists should be limited to operating on “the skin of the foot and those
structures (such as callosities and toe nails) which derive from it” (Lorimer 1995).
The actions of the podiatric surgeons, represented by the Podiatry Association
pursuing a policy of non-negotiation with the medical hierarchy (Larkin 1983),
independently established legal rights to practise podiatric surgery within the private
19
sector and their subsequent campaign for inclusion of podiatric surgery within the
NHS “guaranteed medical hostility” (Borthwick 1999). The response of the
Podiatry Association to the hostile environment in which they worked had been to
develop a policy of rigorous audit practices for surgical fellows, closely monitoring
procedures and outcomes in order to develop an evidence base (Borthwick 1999). In
this way a policy of strict clinical governance allowed the Podiatry Association to
justify practices and present podiatric surgery as a safe and effective competitor to
orthopaedic surgery, to a Conservative government, fundamentally opposed to
monopolies and seeking a solution to long waiting lists. The Griffiths report (House
of Commons Social Services Committee 1983) brought about enormous change in
health service management, ending consensus management and establishing new
general managers, empowered to act across disciplines, at all levels (Webster 2002).
The case for podiatric surgery, based on accessibility, effectiveness and cost
effectiveness met all the criteria set out in the Griffiths report, offering the same
costs and effectiveness as orthopaedic surgery, but much greater accessibility. The
argument that podiatric surgeons were more practised (and therefore more
proficient) in foot procedures than orthopaedic surgeons, served to reinforce support
from general managers (Borthwick 2000). Thus podiatric surgery became
established in the NHS, sanctioned by government and managed by general
managers.
1.5.4 Diabetes Specialist Podiatrists
Unlike podiatric surgeons, diabetes specialist podiatrists have not mounted a direct
challenge to the authority of medicine; they do not appear to be in competition for
medical roles and while medical authority over the profession of podiatry may be
decreasing (see 1.8.3 and 1.8.4), in 2003 Young (2003a) expressed the opinion that
[medical] consultants were still considered to be the leaders of the diabetes team.
Strategies developed by the Association of British Clinical Diabetologists
(Winocour 2010) to ensure that medical consultants retain leadership of diabetes
teams, such as the King’s Fund diabetes leadership course for registrars have been
developed (Department of Health 2008).
20
Podiatrists have a long history of involvement in the management of patients with
diabetes. Specifics of the role of chiropodists in preventing:
“…those distressing complications of the diabetic, infections and gangrene of the lower extremity…”
were outlined in 1925 by the American physician Elliott Joslin, including patient
education in self-care:
“…he [the chiropodist] is it who can instruct in cleanliness…”
and vascular assessment:
“…detect early changes in the circulation from his examination of the
arteries of the feet…” (Joslin1925).
Before the inception of the NHS, appointment (usually without remuneration) of
chiropodists to the larger, mainly teaching hospitals:
“…proved useful in making the value of the chiropodist understood in orthopaedic and diabetic departments” (Lorimer 1995).
1.5.4.1 Drivers for Specialisation in Diabetes Podiatry
The notion that diabetes represented an immense and growing health problem was
first expressed by the Expert Committee on Diabetes convened by the World Health
Organisation (WHO) in the late 1970s (Keen 2000). The subsequent 1985 WHO
Study Group Report linked improved quality of care to specialised diabetes
provision, recommending that:
“Community-based primary health care schemes should be linked to specialized levels to optimise the quality of care, depending on the
requirements of the patient and the availability of resources…” (WHO 1985, cited in Keen 2000).
In 1989, with the objective of formulating a European diabetes strategy the WHO
convened a meeting in St Vincent, Italy. Targets for reducing the major
complications of diabetes were produced, including reducing limb amputation by
one half. Calls for the employment of more senior-level podiatrists and diabetes
specialist nurses ensued (Connor 1997). At the national level the St Vincent
declaration 5 year target on amputation was not achieved in Britain (Connor 1997),
21
Denmark (Ebskof and Ebskof 1996) or Germany (Trautner et al 2001) and the
declaration has been criticised for setting such ambitious and quantitative targets
(Keen 2000, Trautner et al 2001). However, substantial reductions in the incidence
of amputations have been reported in localities as a consequence of hospital based
diabetic foot clinics, featuring multi-disciplinary teams (which include podiatrists)
working collaboratively to prevent diabetic foot disease (Larsson et al 2008, Ronan
et al 2008, Krishnan et al 2008, Trautner et al 2007, Anichini et al 2007, Lavery et al
2006, Driver et al 2005, Wraight et al 2005, Van Hotum et al 2004, Holstein et al
2000, Dargis et al 1999, Van Gils et al 1999, Crane and Werber 1999, Thomson et al
1991, Edmonds et al 1986) most recently such teams in Ipswich and the Imperial
College Healthcare NHS Trust have amputation rates amongst the lowest in Europe
(Society of Chiropodists and Podiatrists 2011). Inadequacies in provision for the
diabetic foot have been highlighted (Bending and Foster 2004) and calls for the
wider establishment and funding of such teams are made (Rogers et al 2008, Tseng
et al 2007, Bending and Foster 2004, Holland et al 2002). Amputation reduction and
reduced levels of diabetic foot complications have also been linked to treatment by
podiatrists who are considered to employ a unique skill-set (Viehe 2002, Wormwald
1995, Thomson et al 1991).
In Britain, podiatric specialisation in diabetes has become inextricably linked to
working within an inter-disciplinary team. Access to specialist, multi-disciplinary
care (which includes podiatry), for patients with diabetic foot disease is enshrined in
national recommendations and guidelines including:
The National Institute for Health and Clinical Effectiveness guidelines on
Type 2 diabetes: Prevention and management of foot problems (National
Institute for Health and Clinical Effectiveness 2004)
The Scottish Intercollegiate Guidelines Network advice on the management
of diabetic foot disease (Scottish Intercollegiate Guidelines Network 2002)
NHS national support team's Diabetic Foot Guide (NHS Clinical Governance
Support Team 2006a)
Payment by results, diabetes fact sheet (NHS Clinical Governance Support
Team 2006b)
22
1.5.5 Foot in Diabetes UK
Formed via a merger of Scottish Diabetes Specialist Podiatrists and Podiatry
Diabetes United Kingdom, Foot in Diabetes UK describe themselves as “an
organisation dedicated to continuous improvement in the care and management of
people with diabetic foot problems”. In changing the title both bodies sought to
make their existing organisations more interdisciplinary. In 2005 the Foot in
Diabetes UK executive committee consisted of 14 podiatrists and 2 medical doctors,
while at the time of writing (October 2008) 13 podiatrists, 5 medical doctors, 2
nurses and 1 orthotist comprise the executive committee, evidencing some
achievement of this goal. The stated aims of the Foot in Diabetes UK Committee are
to:
“…support healthcare professionals to deliver high quality clinically
effective care in order to improve the lives of people living with diabetic foot problems” and to “become the voice of foot care in diabetes, to influence the
future direction of healthcare policy in this field”. Foot in Diabetes UK (2006)
The group offers free membership and has made a statement of its constitution and
aims (table 4.).
Table 4. Foot in Diabetes UK Constitution and aims
To create a register of interested members.
To develop a network of individuals who have an interest in working with people
with diabetes.
To develop recognised and nationally accredited post-graduate qualifications in the
management of the diabetic foot.
To promote this aspect of podiatry as a speciality in its own right.
To generate an increased awareness of the role of the podiatrist and other members
of the healthcare team within diabetology.
To promote, encourage and support research on the diabetic foot.
To establish links with other appropriate professional organisations and to liaise
with relevant professionals.
To develop an internet-based diabetic foot information resource.
Summarised from: Foot in Diabetes UK (2006) Foot in Diabetes UK (FDUK): Become a member.
Young (2003a) considers that membership of Foot in Diabetes UK will give diabetic
foot practitioners a voice in the process of developing a specialist career structure.
Indeed have been active in developing national policy; in 2006 in conjunction with
Diabetes UK, The Association of British Clinical Diabetologists, The Primary Care
Diabetes Society and The Society of Chiropodists and Podiatrists, Foot in Diabetes
23
UK developed and published the “National Minimum Skills Framework for the
Commissioning of Foot Care Services for People with Diabetes” (Foot in Diabetes
UK et al 2006). The minimum skills framework addresses the skills needed for the
management of the diabetic foot and concentrates on the following issues: routine
basic assessment and care of the foot without any ulcer or lesion; expert assessment
and care of the foot at increased risk, but without an ulcer or lesion; expert
assessment and management of foot ulceration; management of the person whose
foot ulcer or lesion has resolved. A subsequent document, the “Putting Feet First”
report (Foot in Diabetes UK et al 2009) presented a specification and integrated care
pathway for the management of active diabetic foot disease in secondary care,
incorporating preventative measures to reduce the onset of new foot disease whilst
in hospital. The report stressed the need for specialist management of diabetic foot
disease and made the case for the presence of specialised services:
“The specification of specialist services for the management and prevention of diabetic foot disease is one that should be adopted by all hospitals
providing emergency medical care” (Foot in Diabetes UK et al 2009, p5)
Accountability for ensuring adequate service is detailed, responsibility remaining:
“…with the admitting team until care is transferred to a team with specialist interest in the management of disease of the foot.” (Foot in Diabetes UK et al
2009, p7)
This second piece of national policy was underpinned by support from a still wider
group of organisations, being formulated in conjunction with:
Association of British Clinical Diabetologists
Joint British Diabetes Societies Inpatient Working Group
National Diabetes Inpatient Specialist Nurse Group
Primary Care Diabetes Society
Scottish Diabetes Foot Action Group
Society of Chiropodists and Podiatrists
The Vascular Society of Great Britain and Ireland
Welsh Endocrine and Diabetes Society
An explicit link between the specifications of the report and delivery of the
aspirations within the Department of Health (2008a) High quality care for all: NHS
Next Stage Review final report, was made (Foot in Diabetes UK et al 2009), lending
further weight to the document.
24
1.5.6 Education and Career Pathways in Diabetes Podiatry
Young (2003a) highlights the medical career model, consisting of undergraduate
training, followed by basic training and then higher specialist training, making the
point that diabetologists are unlikely to study cardiology or surgery. He contrasts
this sharply with the situation in podiatry which he considers, favours generalism
over specialty (though interestingly the established and successful specialty of
podiatric surgery has emulated this medical career model). Further Young (2003a)
argues that this situation cannot continue, citing the need for each member of the
diabetes foot care team to be a specialist in their own right, and calling for a career
structure for podiatrists and nurses to reflect this. A needs analysis study for
continuing professional development (CPD) in podiatry undertaken by Borthwick
and Vernon (2002) elicited support for a model of CPD “that would recognise as
‘core’ the requirements outlined within the specialty groups”. The authors also
discuss the possibility that institutions other than the Society of Chiropodists and
Podiatrists may play a role in delivering specialty-driven, individual led CPD,
(possibly based upon a specialty-driven CPD framework) and that inter-professional
modes of CPD could present broader educational opportunities within specialties. In
the area of wound healing diabetes specialist podiatrists, diabetes specialist nurses
(DSN) and tissue viability specialist nurses may all have potential involvement. The
interest of, and potential specialisation for several professions in this area is reflected
in the advent of multi-disciplinary education (Jones et al 2004, Sibbald and Orsted
2004, Baxter 2003, Jones 2001).
Frequently the only opportunities for career advancement in podiatry were through
moves into management or teaching (Young 2003b), though the effects of NHS
modernisation may alter this. It remains the case however that diabetes podiatry
lacks any formalised educational preparation for specialisation or agreed career
pathway for progression.
1.5.6.1 Establishment of a Diabetes Specialist Podiatry Assistant Grade
The origins of the foot care assistant (FCA) grade can be traced to 1977, a time of
retention and recruitment problems within podiatry, as a bid to supplement the
numbers of qualified podiatrists (Webb et al 2004). The advent of assistant grades
25
was generally opposed by the podiatry profession (Lorimer 1995, Webb et al 2004).
Eventual approval was bound to a policy of strict supervision, with a defined
structure for FCAs being established during the early 1980s (Lorimer 1995), debates
about the role and function of FCAs continue. The diabetes specialist podiatry
assistant grade is considered by Holland et al (2002) to have a pivotal role within
secondary care, essential to the development of co-ordinated follow-up of those
patients already at high risk of re-ulceration and amputation (Holland et al 2002).
Though within diabetes specialist podiatry the activities, scope and level of skills
attributed to the diabetes specialist podiatry assistant by Holland et al (2002, table
5.) appear to be greater than those with which the Society of Chiropodists and
Podiatrists (2006a and 2006b) policy of supervision for assistant grades (appendix 2)
can be reconciled.
Table 5. Diabetes specialist podiatry assistant - main team role
1. Maintain and update at risk patient register.
2. Initial assessment self-care/social status – identify barriers to self-care.
3. Patient education about foot care/wear, warning signs and when to seek help.
4. Identification of problems with glycaemic control - refer to DSN as necessary
5. Liaise with ward staff/named team about patients' requirements/management issues and record in patients' medical notes as well as diabetes centre patient
notes.
6. Provide education about the diabetic foot on an informal and formal basis with the DSN.
7. Meet with DSN for liaison with patient case studies.
8. Refer to advanced podiatry team for follow-up.
9. Liaise with the multidisciplinary diabetic foot service team as appropriate.
Summarised from: Holland, E., Land, D., McIntosh, S. and Meeking, D. (2002) Development of diabetic foot service since the introduction of a multidisciplinary
diabetic foot referral pathway. Practical Diabetes International, 19(5):137-138.
The diabetes competence framework was launched by Skills for Health in October
2004. Its focus is the routine management of people with diabetes and its intended
use is the development of job descriptions and identification of training needs for
healthcare assistants.
1.5.7 The Image of Diabetes Podiatry
At the first Malvern Diabetic Foot Conference in 1986, chiropody was listed by a
vascular surgeon as one of the causes of gangrene (Foster 2001), while advanced
26
diabetes podiatrists working in the community are frequently blamed for causing
amputations (Bending and Foster 2004). Thus diabetes podiatry is doubly
disadvantaged, there being both issues of low status associated with treating feet
(Mandy 2008, Vernon et al 2005) and poor understanding of what diabetes podiatry
is.
Awareness of the full role that can be played by the podiatrist is still not widespread
and in some quarters podiatrists are still perceived as the ‘bunion-scraping pillock’
described by the GP in Alan Bennett’s film: A Private Function (Foster 2001).
Indeed “having an interest in the diabetic foot is considered by many to be on a par
with train-spotting, anorak-wearing and an ability to memorise all the capital cities
of the world” (Kerr and Richardson 2000).
1.6 Specialisation and Specialist, Conclusion and a Proposed Definition
Evaluation of the concept of specialisation elicits areas of consensus about the
definition of the concept, and therefore a level of conceptual maturity (Morse et al
1996). Within the context of healthcare professions, the pragmatic utility of
“specialisation” and “specialist” (being one who specialises) conveys differentiation,
usually accompanied by stratification. Such differentiation can be based on
activities, roles and functions, education, credentials, client groups, knowledge and
skill levels. Specialists may confine their practice to a specific, identified area or
also undertake some allied generalist roles.
Development of specialisation within healthcare professions is a complex, multi-
factorial process, often occurring over significant periods of time; involving demand
for services, scientific advances, the production of new knowledge, professional
agendas and health policy; though not necessarily in equal measures. Recognition of
specialisation (both social and legal) is bound to issues of status and image, title,
validity and legitimacy, but not necessarily to levels of remuneration.
Before moving on to analyse the maturity of the concept of diabetes specialist
podiatry, the author would conclude the evaluation of specialisation and specialist
27
by suggesting that a definition of specialisation within the context of healthcare
which can be summarised thus:
Differentiation usually accompanied by stratification, based on a variable
blend of client groups, activities, roles and functions, education and credentials, knowledge and skill levels.
Tensions and disparities between the scientific meanings and use of “specialist” and
“specialisation” and the everyday use and meanings assigned to them (with which
the concept analysis opens) are extant. The origins of “specialist” and
“specialisation” from the word “special” may still impart emotive and judgmental
connotations.
The following section (1.6.1) assesses the comparative maturity of specialised
practice within diabetes across three different professions. The literature relating to
diabetology (medical specialisation in diabetes), diabetes specialist nursing and
diabetes specialist podiatry have been interrogated to elicit the preconditions,
characteristics and outcomes associated with specialised practice in diabetes. These
findings are presented in comparative conceptual maturity matrices (tables 6. to 14.)
and discussed in section 1.6.2.
28
1.6.1 Comparative Concept Maturity Matrices
Three areas of critical enquiry were used to assess the comparative maturity of specialist practice in diabetes across the professions of podiatry, nursing and medicine:
1. Preconditions for specialist practice in diabetes (table 6.) 2. Characteristics of specialist practice in diabetes, including:
Ways of working (table 7.), Services provided (table 8.), Assessment (table 9.), Management, (table 10.), Educational output (table 11.) and Service and policy (table 12.)
3. Outcomes and consequences of specialist practice in diabetes, including: Professional (table 13.) and clinical outcomes (table 14.)
Table 6. Preconditions for specialist practice in diabetes.
Podiatry Nursing Medicine
Graduate status in podiatry. Threshold set via Benchmark Statements published by the Quality
Assurance Agency (QAA) for the Department of
Health in 2001 defining threshold levels of both academic and clinical achievement (including
management of the diabetic foot) for graduate status in podiatry (McInnes 2002).
Postgraduate training varies, comprised by a mix of recognised MSc modules, the Hospital
Podiatrists Panel Diabetic Foot Module(Robbie
2002, Rayman et al 2000), ENB 928 Diabetes in Practice course, pharmacology (prescribers'
course) (Robbie 2002) and short courses and study days including Scotch-casting, wound care
and cultural awareness (Robbie 2002) and
conference attendance (Rayman et al 2000).
Post-registration training (varying) is undertaken by 80% of nurses to prepare for specialism in diabetes (Liahana 2003).
ENB928 is the standard against which education and practice can be evaluated (Young 2002), 88% of employers stipulated ENB928 as a
requirement (Winocour et al 2002a); ENB928 was often used as an entry requirement (Da Costa 2002).
ENB 928 no longer extant, now diabetes nurses gain access to education “when and where they can” (MacKinnon 2002). Entry criteria vary,
there is no agreement or consistency nationwide regarding entry level,
roles and titles (Da Costa 2002) and no agreed national training programme (Cradock 1999).
Of 299 diabetes nurse specialists surveyed:
Professional registration only 12%
Registration plus ENB928 (short course) 39% Registration plus ENB870 (introduction to research) 2.3%
Defined, route to specialist status:
1. Initial graduation and
registration with the General Medical Council.
2. Two years of general professional training in an
approved senior house officer
post. 3. Membership of the Royal
College of Physicians.
4. Obtain a post with a national training number as a
specialist registrar in diabetology and
endocrinology (four years
further training). Some doctors achieve an MSc
29
No standards against which education or practice can be evaluated. No clinical examinations, no
apprenticeship, no career pathway (Young 2002).
Specialist titles can be self-appointed or adopted
with little merit (particularly in the community) (Rayman et al 2000).
There may be qualifying podiatrists who do not have sufficient expertise to provide high quality
diabetic foot care (McInnes 2002, Rayman et al
2000).
Practitioners for specialist centers can be community podiatrists (Young 2002). Care
provided by a ‘dedicated’ diabetic podiatrist
shows wide regional variation, from 55% (Northern and Yorkshire) to 100% (Northern
Ireland) (Winocour et al 2002b).
Podiatrists are uniquely qualified in basic
debridement, vascular, neuropathic, and biomechanical structure and functional
assessments, and off-loading strategies (Young
2002).
Key skills are debridement of calluses and ulcers
and the diagnosis and management of minor foot disorders (Foster 2001).
Registration plus ENBA05 (Diabetes Nurse Specialist course) 2.3% Bachelor’s degree 17.7%
Master’s degree 4%
PhD 0.7% (Humphris et al 1999).
Of 599 diabetes nurse specialists surveyed: 85.3% had completed accredited courses relevant to their current
position, 74.3% the basic diabetes course, ENB 928 (Thompson et al
2002).
Nurse consultant in diabetes (7 posts extant in 2002) is allied to clearer
entry requirements prospective post holders are expected to have a first degree and master’s degree, or commitment to undertaking a master’s
degree (Da Costa 2002).
Attending national and international conferences and workshops (Bale
2002).
Continuing professional education and development (Siddens and
McAughey 1992).
Skills in communication, counseling, motivating and education (Wallymahamed et al 2003)
Clinical practice and expertise in diabetes (Da Costa 2000). Expertise in nursing people with diabetes (Watkinson 1998).
Clinical, teaching and counselling skills (Hicks 1999a).
during this phase. 5. Certificate of completion
of specialist training in
diabetology and endocrinology awarded for
successful completion of a recognised specialist registrar
training scheme, run by the
Specialist Training Agency. 6. Entry to the GMC
specialist register, eligible for
consultant diabetologist post.
Summarised from Health Career Net
http://www.healthcareernet.co
.uk/Physician/CareerProfiles/PID00179.aspx (accessed
13.11.06)
Research and audit training
an integral part of education (Winocour et al 2002a).
Consultant is the member of the team most up
to date in
the specialty (Gask 2005).
30
Table 7. Characteristics of specialist practice in diabetes - Ways of working.
Podiatry Nursing Medicine
Membership of multi-disciplinary team
(Krishnan et al 2008, Ronan et al 2008, Bending and Foster 2004, Parr et al
2002, Robbie 2002, Boulton 1998,
Boulton et al 1998, Siddons and McAughey 1992, Thomson et al 1991,
Edmonds et al 1986) though in 2000 a
coordinated ‘team’ approach to foot care still took place in less than 50% of
secondary care centres (Winocour et al 2002b).
Shared management planning (Thomson et al 1991).
Shared assessment and management of non-ulcerated painful neuropathy
(Murphy et al 2002).
Joint diabetologist/podiatrist clinic for
painful neuropathy not responding to first-line treatment (Murphy et al
2002).
Joint footwear clinic with orthotists
(Robbie 2002).
Membership of multi-disciplinary team (Krishnan et al 2008, Ronan et al
2008, Bale 2002, Parr 2002, Hicks 1999a, Boulton 1998, Boulton et al 1998, Lowes 1997, Siddons and McAughey 1992, Thomson et al 1991).
Working exclusively in diabetes care (Hicks 1999a, Watkinson 1998). Of 599 diabetes nurse specialists surveyed, 71.0% were employed full-
time in their current positions (Thompson et al 2002).
Employment almost exclusively within the NHS (Winocour et al 2002a),
of 599 diabetes nurse specialists surveyed the majority (69.2%) normally worked between hospital and community settings, 24.7% were hospital-
based and 6.1% community-based (Thompson et al 2002).
Banding assigned to specialist posts varies widely (Winocour et al
2002a, Da Costa 2000); posts lack uniformity of remuneration (Da Costa
2000, Watkinson 1998), titles, responsibility, career pathway or role definition (Da Costa 2000).
Clinically accountable to the consultant diabetologist (Wroe 2002).
Shared role in managing late complications of diabetic neuropathy (Boulton et al 1998).
Following the patient across organisational boundaries (e.g. hospital to home or school) (Hicks 1999a).
Own clinical caseload (Sadler 1990).
Membership of multi-disciplinary team
(Krishnan et al 2008, Ronan et al 2008, Parr et al 2002, Boulton 1998, Boulton et
al 1998, Siddons and McAughey 1992),
leadership of multidisciplinary team implied (Thomson et al 1991, Winocour
et al 2002a, 2002b).
Shared role in managing late
complications of diabetic neuropathy (Boulton et al 1998). Shared management
planning (Thomson et al 1991).
Joint diabetologist/podiatrist clinic for painful neuropathy not responding to
first-line treatment (Murphy et al 2002).
Supervise the role of allied health
professionals (Kanton et al 2001). Advising diabetes specialist podiatrists
and diabetes specialist nurses managing
non-ulcerated painful neuropathy, providing prescription only medications
for patients as needed (Murphy et al
2002).
Work closely with general practitioners
and specialist nurses or therapists,
31
Shared role in managing late complications of diabetic neuropathy
(Boulton et al 1998).
Working with peer health educators in
providing diabetic foot education (Robbie 2002).
Referral of patients to vascular consultant or orthotist as required
(Robbie 2002).
Develop and maintain close links with
community podiatrists, acting as a resource and accepting referrals from
them (Bending and Foster 2004).
Enhanced communication and collaboration (Holland et al 2002).
Rolling out screening programmes to
primary care (Robbie 2002). Improved links with community nursing teams
(Robbie 2002).
Accept referrals from diabetes specialist podiatry assistant (Holland et al
2002).
In 60% of trusts out of hours working (Winocour et al 2002a). Evening
and weekend working to provide house-calls to children with diabetes (Lowes 1997).
Liaising with medical colleagues at any time for prescription of insulin dosage and advice (Lowes 1997).
Referral to medical colleagues (Cradock 1999).
Enhanced communication and collaboration (Holland et al 2002).
Liaison with primary care teams, particularly practice nurses (Wroe
2002, Winocour et al 2002a). Acting as a link between hospital and community care (MacKay 2002).
Link person within diabetes team and with primary care (Sadler 1990).
advising on treatment and lifestyle alterations using a “stepped care”
approach. Provide the specialist overview
– being most up to date in specialty (Gask 2005).
For paediatric consultant – manning out
of hours telephone helpline (Lowes 1997).
Take over care for patients with adverse
outcomes despite level 3 care or those
with higher initial level of complexity (Kanton et al 2001).
Direction of shared and integrated
diabetes care services (Wroe 2002).
Most consultant diabetologists also
provide an endocrine service and make a
substantial contribution to acute general
medicine (Greenwood 2005).
32
Table 8. Characteristics of specialist practice in diabetes - Services provided.
Podiatry Nursing Medicine
Provide service to meet the needs of medium and high risk patients (Holland et al 2002).
Provide a rapid-access service (Bending and Foster 2004, Robbie 2002, Foster 2001).
The majority (82%) of trusts provided podiatry services for both ‘trouble-shooting’
and regular foot checks and advice to patients, although urgent access ‘trouble-shooting’ alone was offered in 15% of responses (Winocour et al 2002b).
Provide pre and post-operative support and counselling for amputees (Bending and Foster 2004).
Provision of preventative treatment:
Prevention of diabetic neuropathic ulcers by callus removal (Foster 2001, Thomson et
al 1991, Edmonds et al 1986).
Provision of customised orthoses (Foster 2001, Wormwald 1995), provision of special
footwear (Robbie 2002, Boulton et al 1998) or making adaptations to footwear (Foster 2001). Input in this area appears variable, podiatrist fitting and application of foot
protective apparatus was only recorded in 61% of diabetologists’ responses and was absent in 15% (Winocour et al 2002b).
Nurse-led clinics (Miles 2002) and services (Cradock
1999).
Manning telephone helpline
(Rayman 2000, Cradock 1999) both in hours (Miles
2002) and out of hours
(Winocour et al 2002a, Lowes 1997).
Provision of telephone
appointments (Miles 2002).
Supporting home-care for
children newly-diagnosed
with diabetes (Lowes 1997).
Maintaining a register of patients with diabetes
(Mackay 2002).
For paediatric consultant – manning out of hours telephone helpline
(Lowes 1997).
Advising general practitioners and
specialist nurses or therapists on treatment and lifestyle alterations
using a “stepped care” approach
(Gask 2005).
Assume responsibility for care of complex patients and those with
adverse outcomes (Kanton et al
2001).
Provision of diabetology service, a
broader endocrine service and
substantial contributions to acute
general medicine (Greenwood 2005).
33
Table 9. Characteristics of specialist practice in diabetes – Assessment.
Podiatry Nursing Medicine
Assessment of risk factors for ulceration (Thompson et al 2004) and assessment of high-risk patients (Holland et al 2002).
Shared assessment and management of non-ulcerated painful
neuropathy, ordering extensive haematology screening to
exclude other causes of neuropathic pain, Doppler assessment to exclude pain secondary to compromised circulation and
referral for biomechanical assessment to exclude musculo-
skeletal pain (Murphy et al 2002).
Assessment and classification of ulceration (Mousley 1998).
Over 70% of diabetologists sampled indicated that diabetes
specialist podiatrists employed in their service used at least one form of equipment to assess peripheral neuropathy (Winocour
et al 2002b).
Access to isotopic and/or MR foot imaging and peripheral
angiography and angioplasty were recorded in 83% of responses (Winocour et al 2002b).
Undertaking individualised assessments (Hicks 1999a).
Assessment and classification of ulceration (Bale 2002, Mousley 1998). Detailed record keeping including ulcer charting (Bale 2002).
Undertaking patient neuropathy assessments (Bale 2002).
ABPI (Bale 2002).
Recording physical and biochemical parameters (osmotic symptoms –
polydipsia/ polyuria, Body mass index, BP, HbA1c, total cholesterol, HDL cholesterol ratio, smoking habits) (Wallymahamed et al 2003)
Screening for diabetic complications (Sadler 1990) and ensuring that screening for diabetic complications is up to date (Mackay 2002).
Shared assessment and management of non-ulcerated painful neuropathy, ordering extensive haematology screening to exclude
other causes of neuropathic pain (Murphy et al 2002).
Examination and diagnosis of
peripheral neuropathy
(Thomson et al
1991).
Screening for
diabetic complications
(Sadler 1990).
34
Table 10. Characteristics of specialist practice in diabetes – Management.
Podiatry Nursing Medicine
Diagnosis and management of minor foot disorders (Foster 2001).
Treatment of at-risk and high-risk patients (Robbie 2002)
Shared management of non-ulcerated painful neuropathy (Murphy et al 2002).
Role in management of diabetic ischaemic foot: Meticulous care of nails
(Edmonds et al 1986).
Ulceration prevention by removal of callus from sites of high pressure and
provision of nail care (Thomson et al 1991).
Manufacture and application of plaster-casts (Winocour et al 2002b, Foster
2001) indicated by 39% of diabetologists sampled (Winocour et al 2002b).
Fitting of orthoses (Foster 2001) indicated by 59% of diabetologists sampled
(Winocour et al 2002b).
Fitting of ‘scotch cast’ boots indicated by 49% of diabetologists sampled (Winocour et al 2002b).
Fitting of other foot protective apparatus indicated by 61% of diabetologists sampled (Winocour et al 2002b).
Availability of ‘aircast’ boots indicated by 52% of diabetologists sampled (Winocour et al 2002b).
Role in management of foot ulceration:
Ulcer treatment including dressing (Rayman 2000, Edmonds et al 1986)
and debridement (Bale 2002).
Management of glycaemic control
(Holland et al 2002, Boulton et al 1998).
Advising patients about their diabetes medication (James 2004, Loveman et al
2006).
Adjusting dosages of hypoglycaemic
agents (in 77% of Trusts) (Winocour et al 2002a).
Optimising blood glucose control (Murphy et al 2002, Rayman 2000),
including where appropriate the use of insulin pumps (Murphy et al 2002).
Adjusting doses of insulin (Loveman et al 2006).
Commencement of insulin therapy for type 2 diabetics (Sutton 2000).
Patient re-education and dietary advice
Shared management planning (Thomson et al 1991). Joint
Diabetologist/Podiatrist clinic for painful neuropathy not responding
to first-line treatment (Murphy et al
2002).
Management of patients with
painful neuropathy and diabetic amyotrophy (Boulton et al 1998)
Management of glycaemic control
(Boulton et al 1998).
Consult with patient and primary
care physician. Recommend
changes in medication and/or lifestyle. (Kanton et al 2001)
Take over care for patients with
adverse outcomes despite level 3
care or those with higher initial level of complexity (Kanton et al
2001).
Advising diabetes specialist
podiatrists and diabetes specialist nurses managing non-ulcerated
35
‘Prescription’ of local treatments and dressings indicated by 88% of diabetologists sampled (Winocour et al 2002b).
Use of ‘Dermagraft’ indicated by 27% of diabetologists sampled (Winocour et al 2002b).
Use of ‘Regranex’ indicated by 22% of diabetologists sampled (Winocour et
al 2002b).
Treatment of diabetic patients with active foot ulceration by sharp
debridement (Foster 2001, Mousley 1998).
Role in management of diabetic neuropathic foot; ulcer treatment by callus
removal which facilitates wound drainage (Thomson et al 1991, Edmonds et al 1986).
(Young, A. et al 2002). Management of intercurrent illness
(Loveman 2006).
On-going monitoring of patients
(Rayman 2000).
Coordinating the on-going care of
patients (Loveman et al 2006) and facilitating delivery of care to patients
(Rayman 2000).
Responsibility for not undermining
other health professionals (Loveman et al 2006)
painful neuropathy, providing prescription only medications for
patients as needed (Murphy et al
2002).
Prescription of diuretics and analgesics (Edmonds et al 1986)
and antibiotics (Mousley 1998
Edmonds et al 1986), ordering x-rays and arranging admissions
(Mousley 1998).
36
Table 11. Characteristics of specialist practice in diabetes - Educational output.
Podiatry Nursing Medicine
Patient education (Robbie 2002, Foster 2001, Sutton 2000, Wormwald 1995, Boulton et al
1998). Patient education sessions had input from podiatry staff in 84% of diabetologists’
responses (Winocour et al 2002b).
Provision of training and clinical supervision
of doctors and nurses in callus debridement
(Bale 2002).
Provision of staff training events, student teaching and shadowing opportunities (Robbie
2002).
Giving presentations at national conferences
and in-house training events (Robbie 2002),
Submitting work to publications that promote
the foot screening service within the NHS arena (Robbie 2002).
Patient education (Loveman 2006, Winocour et al 2002a, Rayman 2000, Boulton et al 1998, Watkinson 1998, Baksi 1995, Siddens and McAughey
1992, Sadler 1990), counselling (Loveman 2006, Rayman 2000, Watkinson 1998) and advocacy (Rayman 2000). Education includes group education
sessions (Miles 2002) and encompasses: lifestyle changes (such as diet,
activity, smoking cessation and adherence to medication), the benefits of optimal glycaemic control and cardiovascular risk reduction Wallymahmed et
al 2003), use of home monitoring, injection techniques and insulin dose
adjustment (Baksi 1995) and foot health education (Sutton 2000).
Patient re-education, dietary advice and insulin dose adjustment (Young, A. et al 2002).
Provision of age-banded education sessions for children with diabetes (Lowes 1997).
Education of professional and non-professional carers (Cradock 1999).
Compilation and provision of a range of educational materials (Lucas and Walker 2004, Mackay 2002).
Educating colleagues and other health professionals (Loveman et al 2006, Winocour et al 2002a). Educating and supporting Practice Nurses (Farmer
2000). Provision of education and support to generalist nurses, facilitating
their patient-education activities (McDermott 1995). Provision of education for patients, nursing and medical students and postgraduate nurses (Sadler
1990). Advising the multi-disciplinary team regarding dressings (Mousley 1998).
Patient education (Boulton et al 1998). Foot health
education for patients (Sutton 2000).
Consultant has an educational role through regular meetings
with staff at all levels (Gask
2005).
Provision of education for primary care practitioners
(Greenwood 2003).
Provision of training and
supervision for Podiatrists
and Nurses in neuropathic assessment (Bale 2002).
37
Table 12. Characteristics of specialist practice in diabetes - Service and policy, table.
Podiatry Nursing Medicine
Development of services, local policy and guidelines: –
e.g. foot screening and joint clinics with other professionals (Robbie 2002), referral pathways
(Holland et al 2002), Joint diabetic wound care
guidelines, Antibiotic guidelines for the infected diabetic foot and formalised
Discharge guidelines for the care of the diabetic
foot (Holland et al 2002), negotiation of fast-track referral routes to vascular surgery (Robbie
2002)
Research and development of services (Holland
et al 2002), including devising assessment tool (Robbie 2002)
Development of services in primary care (Mackay 2002) including quality improvement (Cradock 1999).
Promotion of shared care. Acting as a resource for patients, staff and carers (Mackay
2002).
Developing systems of care (Cradock 1999) and health promotion programmes (Siddens
and McAughey 1992).
Evaluation and integration of research into practice (Humphris et al 1999).
Generation of research evidence (Winocour et al 2002a, Humphris et al 1999, Watkinson 1998, Siddens and McAughey 1992).
Audit activity (Winocour et al 2002a, Rayman 2000).
Professional leadership (Cradock 1999).
Leadership role in bringing
about innovation
and
change (Gask
2005)
Direction of
shared and integrated
diabetes care services (Wroe
2002).
38
Table 13. Professional outcomes and consequences of specialist practice in diabetes.
Podiatry Nursing Medicine
Blurring of professional roles (Bale 2002).
Highlighted need for increased podiatry input into
paediatric services – such input is low, of 91 paediatric
diabetic services sampled only 3% had podiatry input (Winocour et at 2002b).
Podiatry access at all diabetic clinics increased the
likelihood of associated preventative as opposed to
reactive ‘trouble shooting’ care (P < 0.05) (Winocour et al 2002b).
Highlighted need for structured, recognised postgraduate training (Rayman et el 2000) and desire to produce a
competency based national standard for diabetes specialist podiatrists at advanced level; utilising a
pupilage model similar to that used by podiatric surgery
(Young 2002, Rayman et al 2000). Such a pupilage to be based in major centers for diabetic foot care that are able
to demonstrate good practice, audit of process and
outcomes, and ability to teach. As well as specific foot pathologies the course will provide knowledge and skills
in general diabetes (Young 2002).
Establishment of multidisciplinary referral pathways
(Holland et al 2002).
Blurring of professional roles (Bale 2002). Overlapping of roles within
diabetes team (Sadler 1990).
Used as role models by other nurses (Cradock 1999).
Nurse-led services in diabetes (Wallymahamed et al 2003, Miles 2002,
Cradock 1999), clinics in primary care often have little or no GP involvement (Wroe 2002, Rodgers 1999).
Dilemma for diabetes specialist nurses forced to choose between allocating time to clinical activities with patients or to educating colleagues (Farmer
2000, Rodgers 1999).
Increased knowledge and skills in wound care Bale 2002).
Development of sub-specialties:
Paediatric diabetes specialist nurse (Winocour et al 2002a, RCN 1999,
Lowes 1997). Renal specialist diabetes nurse (Marchant 2002, Atherton 2004, Marchant
2008).
Diabetes specialist midwife (Siddons and McAughey 1992). Diabetes foot educator (Siddons and McAughey 1992).
Evolution of roles for diabetes specialist nurses in private occupational
health schemes (O’Driscoll 2005) and advent of consultancy roles for
diabetes related companies (e.g. pharmaceuticals) (Rodgers and Walker 1999).
Blurring of
professional roles. (Bale 2002).
Development of sub-specialty of
Paediatric endocrinology/diab
etology (Edge et al
2005).
Generation of
interest within and enhanced
communication with specialties not
originally
connected to the multidisciplinary
team and hence
team expansion – involving
orthopaedic surgeons and
elderly care
physicians in the team (Holland et al
39
Establishment of multidisciplinary assessment tools (Elliott et al 2002, Holland et al 2002).
Increased number of face-to-face contacts (Mousley 1998) and increased workload for podiatrists (Holland et
al 2002).
Highlighted need to improve communication with
primary care (Mousley 1998).
Highlighted need for outcome monitoring and clinical
audit (Holland et al 2002, Mousley 1998).
Identification of a specialised role for assistant practitioners and development of formal diabetes
specialist podiatry Assistant posts (Holland et al 2002).
Generated interest within and enhanced communication
with specialties not originally connected to the
multidisciplinary team and hence team expansion – involving orthopaedic surgeons and elderly care
physicians in the team (Holland et al 2002).
Improved staff awareness of diabetic foot disease
(Robbie 2002).
Improved profile of podiatry with key stakeholders
(Robbie 2002).
Continuing professional development is an issue for podiatry staff involved in the foot screening service
(Robbie 2002).
Formation of the UK Association of Diabetes Specialist Nurses in 1997 by diabetes specialist nurses with the explicit purpose of providing a national
voice for diabetes specialist nurses (Da Costa 2000).
Interests of diabetes specialist nurses represented by the Royal College of
Nursing Diabetes Forum and The UK Association of Diabetes Specialist Nurses (Winocour et al 2002a).
Need for a career framework for diabetes specialist nurses (Tipson and Turner 2002, Hicks 1999b).
Disagreement over level of academic qualification needed to demonstrate higher level of practice (Hicks 1999b).
Identified need for degree level courses for diabetes specialist nurses
(Winocour et al 2002a).
Diabetes specialist nurses tend to define their own roles and engineer their
own career progression (MacKinnon 2002).
Highlighted need to improve communication with primary care Mousley
1998).
Highlighted importance of administrative support and a reliable call/re-call
system for patients (Mackay 2002).
Highlighted need for outcome monitoring and clinical audit (Mousley 1998).
Generated interest within and enhanced communication with specialties not originally connected to the multidisciplinary team and hence team expansion
– involving orthopaedic surgeons and elderly care physicians in the team (Holland et al 2002).
2002).
40
Table 14. Clinical outcomes and consequences of specialist practice in diabetes.
Podiatry Nursing Medicine
Reduction of amputation rates (Wormwald 1995).
Improved healing rate for diabetic
foot ulcers (Bale et al 2002,
Robertshaw et al 2001). Rate of ulcer healing 60.7% (Bale 2002), 86%
healing rate for neuropathic and 72%
for ischaemic ulceration (Edmonds et al 1986).
Improved record keeping (Wraight et
al 2005, Elliott et al 2002).
Podiatry access at all diabetic clinics
increased the likelihood of associated
preventative as opposed to reactive ‘trouble shooting’ care (P < 0.05)
(Winocour et al 2002b).
Empowered patients to take
responsibility for their own foot care, supported by the specialist podiatrists
(Robbie 2002).
Improved healing rate for diabetic foot ulcers (Bale 2002, Robertshaw et al 2001). Rate of ulcer healing 60.7% (Bale 2002), 86% healing rate for neuropathic and 72% for ischaemic ulceration (Edmonds et al
1986).
Improved recording of ulcer status, facilitating outcome assessment (Bale 2002).
Increased dressing costs Mousley 1998).
Intensive nurse-led intervention over a short period of time has beneficial effects on glycaemic control, BP and lipid profiles, without a significant increase in BMI. No reduction in BMI or reduction in
number of current smokers was achieved (Wallymahmed 2003).
For diabetes patients with poorly controlled blood glucose levels almost two-thirds (63%) of patients
achieved improvement status, with no increase in body weight or hypoglycaemic episodes. Disappointingly, however, the non-improver group (37%) showed a mean deterioration in HbA1c.
(Young, A. et al 2002).
Reduced non-attendance rates in paediatric and adolescent diabetes clinics (Lowes 1997).
Reduced length of hospital stays for children with diabetes (Lowes 1997).
Reduced length of hospital stay and increased levels of satisfaction (in inpatient settings) (Davies et al 2001).
Improved screening programme for diabetic complications (Mackay 2002).
Improved healing rate
for diabetic foot ulcers
(Bale 2002).
Rate of ulcer
healing
60.7% (Bale 2002), 86%
healing rate for
neuropathic
and 72% for ischaemic
ulceration
(Edmonds et al 1986).
41
1.6.2 Maturity of the Concept of Diabetes Specialist Podiatry
Examining the conceptual components (the pre-conditions, characteristics of
practice, outcomes and consequences) of specialist practice in diabetes across
podiatry, nursing and medicine elicits significant inter-disciplinary differences
(tables 6-14). Differences are most marked between medicine and the other two
professions.
1.6.2.1 Preconditions of Specialised Practice in Diabetes (table 6):
Medicine shows a clear route of progression culminating in specialist status as a
consultant in diabetes. While actually attaining a diabetologist’s post will in part be
dictated by vacancies; eligibility to apply is bound to a defined period of training
and the attainment of a recognised, validated qualification. Unlike the case of
medicine, podiatric and nursing specialisation in diabetes lacks clear pre-conditions.
Eligibility to apply for a post specialising in diabetes is not linked to any educational
or experiential pre-requisites and incumbents in post display wide variation in
qualifications.
1.6.2.2 Characteristics of Specialised Practice in Diabetes:
Ways of working (table 7.)
While nurses, podiatrists and medical doctors specialising in diabetes may all be
members of a multi-disciplinary team, leadership of such a team is linked to the
medical doctor. Supervision and guidance of nursing and podiatry team members
and direction of integrated care services are considered to be the diabetologist’s
remit. The diabetologist’s role is also considered to fulfil the level 4 stage in
Kanton’s “stepped care model” (Kanton et al 2001), discussed in section 1.2 of this
document. Across medicine, podiatry and nursing while some characteristics of
practice demonstrate boundary blurring and shared roles, leadership and supervision
are linked to the diabetologist.
Nurses and podiatrists show more activities which cross organisational boundaries.
For nurses this often involves working in both primary and secondary care venues,
while for podiatrists the development and maintenance of close links with the
community podiatrists, acting as both a resource and a point of referral, is
considered central. Such referrals may also link podiatrists to level 3 and 4 activity
42
in Kanton’s stepped care model, though given the supervisory role over podiatrists
ascribed to the diabetologist the podiatrists may represent an interface or
intermediate step within the model.
Services provided (table 8.)
For diabetologists services provided were closely linked to Kanton’s stepped care
model of provision; responsibility for the care of complex patients residing with the
medical doctor specialising in diabetes. A more generalist role for diabetologists
was also described, highlighting their input into the broader field of endocrinology
and general medicine.
Provision of rapid access, either through manning a telephone help line (nurses and
medical doctors) or offering a rapid-access service (podiatrists) was ascribed to all
three professions. However services provided by nurses specialising in diabetes
were linked to home-care activities, provision of nurse-led clinics and maintenance
of a register of patients. Services provided by podiatrists were linked to the risk
stratification of patients, where the needs of medium and high risk patients were to
be met by podiatrists specialising in diabetes. Preventative measures were also
linked to the diabetes podiatrists, specifically callus removal, provision of
customised orthoses, adapting footwear or providing special footwear.
Assessment (table 9.)
For diabetologists assessment activity was couched in the broad term of diabetic
complications, though peripheral neuropathy was also mentioned specifically. This
breadth of approach was also evident in the assessment activities ascribed to nurses
and podiatrists, with attention to a wide range of biochemical, vascular and physical
parameters. Assessment and classification of ulceration was mentioned specifically
for nurses and podiatrists, as was assessment of neuropathy. Access to imaging and
advanced vascular assessment was mentioned within the podiatrist’s activities. Thus
assessment activities show a more comparable pattern across the three professions
than other characteristics of practice.
43
Management (table 10.)
Diabetologists roles are considered to be management of complex patients and those
with complications, taking over the care of patients with adverse reactions despite
what Kanton et al (2001) describe as level 3 care. For this group of patients the
diabetologists’ management activities are highlighted as those pertaining to
glycaemic control and provision of prescription only medicines related to pain,
infection, cardio-vascular and renal function. A role in advising nurses and
podiatrists specialising in diabetes regarding their patient management activities is
also linked to the diabetologist.
The nurses’ activities also strongly feature the management of glycaemic control,
specifically commencement of insulin therapy, the use of insulin pumps, dose
adjustment of hypoglycaemic agents, medication and dietary advice. Common
management activities across nursing and podiatry were ulcer treatment, specifically
dressing and debridement. Debridement strategies featured autolytic, dressing
mediated measures and “sharp” debridement, though “sharp” debridement was
linked more closely to the podiatrists. Management by podiatrists specialising in
diabetes was again linked to a risk-stratified patient group with the foot being the
focus of their activities. Podiatrist’s management strategies in addition to wound
management were considered to include provision of specialist footwear, offloading
strategies and orthoses. Role sharing in the management of painful neuropathy was
considered to exist, involving podiatrists and diabetologists.
Thus once more, while there are some shared management activities, overall control
and direction of patient’s management is linked to the diabetologist.
Educational output (table 11.)
Practitioners specialising in diabetes from all three professions were considered to
have a role in patient education (including foot health education); however while the
diabetologist was considered to have an educational role for staff at all levels; the
nurses’ and podiatrists’ educational remit was more defined.
Nurses’ educational activities were focussed mainly on patients; preparation and
provision of educational material, a wide range of group and individual educational
44
sessions for adults and children, covering areas such as glycaemic control, home
monitoring, self-injection techniques and lifestyle change being part of their role.
The podiatrists’ role in patient education was also highlighted.
Nurses’ and podiatrists’ role in educating other health professionals was of a more
defined nature than the broad remit ascribed to diabetologists. For nurses this
included education of professional and non-professional carers, colleagues, practice
nurses, generalist nurses, nursing and medical students and postgraduate nurses.
The podiatrists educational output featured provision of staff training events, student
teaching and shadowing, presenting and publishing work at local and national levels.
The area where nurses were considered to advise the multi-disciplinary team
(including the diabetologist) was that of dressings, while podiatrists’ activities in
training and supervising doctors and nurses in callus debridement ascribed them
leadership within this area.
Diabetologists were assigned a broad educational remit for staff at all levels, mainly
through meetings - with leadership of such meetings linked to them as medical
consultants. The nurses and podiatrists were considered to lead educational
provision in a specific defined area – namely for nurses dressings and for podiatrists
callus debridement.
Service and policy (table 12.)
Diabetologists were assigned a leadership role in effecting innovation and change at
service and policy level, with the direction of shared and integrated care services
residing firmly with the consultant diabetologist. In contrast to this nurses’ and
podiatrists’ roles were described in terms of service development, promotion,
evaluation and integration. Podiatrists’ and nurses’ generation and integration of
research was highlighted and for the podiatrists the production of formal guidelines
was a focus.
1.6.2.3 Outcomes and Consequences of Specialised Practice in Diabetes.
Professional outcomes (table 13.)
45
While blurring of boundaries and overlapping of roles was considered to occur
across the three professions, the consequences of medical specialisation in diabetes
mainly focussed on the effects engendered in the wider healthcare team. Specialist
practice in diabetes was considered to promote an interest in diabetes within other
specialists and hence was linked to expansion beyond the “core” diabetes team. The
only intra-professional effect noted for the diabetologists was the generation of sub-
speciality. While such sub-specialisation is also noted for diabetes podiatrists and
nurses, intra-professional effects highlighted the need for post-graduate training and
a framework for career progression. Increased workload for podiatrists and nurses
as a consequence of their specialised focus was considered to pose a dilemma for
nurses faced with competing demands; for podiatrists this increased workload has
been highlighted as a driver for the establishment of assistant posts within the
specialty.
Specialisation in diabetes for podiatrists and nurses was considered to improve the
profile of both professions. One of the consequences of the podiatrists’ specialist
activity was also improved awareness of diabetic foot disease. The value of robust
administrative, monitoring and clinical audit activity and the need to improve
communication with primary care centres were further outcomes linked to the
activities of nurses and podiatrists.
Thus while boundary-blurring and initiation of sub-specialisation are noted for all
three professions, marked differences in the professional consequences of
specialisation in diabetes were evident. For medicine the intra-professional impact
appears comparatively small, however for podiatry and nursing, educational and
organisational needs and the effects of increasing workloads were highlighted.
Clinical outcomes (table 14.)
Focussing on diabetic foot disease (see section 1.5.3.1), improved outcomes have
been reported as a consequence of hospital based diabetic foot clinics, featuring
multi-disciplinary teams (Larsson et al 2008, Ronan et al 2008, Krishnan et al 2008,
Trautner et al 2007, Anichini et al 2007, Lavery et al 2006, Driver et al 2005,
Wraight et al 2005, Van Hotum et al 2004, Holstein et al 2000, Dargis et al 1999,
Van Gils et al 1999, Crane and Werber 1999, Thomson et al 1991, Edmonds et al
46
1986, Society of Chiropodists and Podiatrists 2010). However references to clinical
outcomes for each profession individually are sparse. Improved record keeping was
linked to both nursing and podiatry. Beneficial effects on glycaemic control have
been associated with nursing intervention, as has reduced in-patient stay times and
reduced non-attendance rates. Access to podiatry within the diabetic clinic has been
linked to increased likelihood of preventative as opposed to reactive care and
support of diabetes podiatrists has been associated with improved empowerment for
patients in managing their own foot-care.
Outcome evaluation has been undertaken mainly for the multi-disciplinary team,
rendering meaningful assessment of each profession’s effects in isolation
impossible.
1.6.3 Conceptual Maturity of Diabetes Specialist Podiatry
While the concept of “specialisation” and “specialist” (being one who specialises)
demonstrates a level of conceptual maturity (see section 1.6), the concept of diabetes
specialist podiatry remains immature. It lacks clear pre-conditions, demonstrates
variation in characteristics and in a cyclical pattern the intra-professional outcomes
highlight the absence of clear, repeatable pre-conditions.
1.7 Specialisation – Overview of Theoretical Frameworks
Weber (1964) described specialisation as a defined sphere of competence, involving
the division of labour within a clearly defined hierarchy and a supervisory system
based on authority. This “rational bureaucratic theory of complex organisations”,
may account for the hierarchical nature of the caring professions which is a legacy
of the way in which they have developed under the (frequently constraining
influence of the dominant profession of medicine). However it offers a poor fit for
organisations in which professionals work (Bucher and Stelling 1969) and fails to
account for the indefinite structures of role division, equivocal rules and non-
specific goals which are a feature of hospitals (Joas 1987).
Contrastingly, Everett Hughes in his studies of occupational sociology, related
patterns of activities which are specialised in accordance with a division of labour,
47
to the impact of divergent interests, relations of forces and processes of negotiations
(Joas 1987, discussed further in sections 1.7.1, 1.7.3.2, 1.7.3.3). Focussing upon the
graduate professions, he argued that only by examining the action of individuals or
occupational groups can the division of labour be understood, and that such
professionals were able to a large extent to create their own roles. He examined the
ideologies of the different professions as a means of achieving freedom from control
and attaining high status.
Abbott (1988, p106) considers that “specialisation most commonly arises because
the skills applicable to a given task area develop beyond the ability of single
practitioners”, though, less commonly also through “differentiation in an exogenous
social structure shaping the profession, such as divergence in client groups”.
Changing health policy and the advent of what may be termed population focussed
services, supported by national frameworks (e.g. the NSF for diabetes) and
guidelines specific for the client group such as National Institute for health and
Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines network (SIGN)
guidelines may represent such exogenous phenomena. Further, Abbott (1988, p77)
also states that “differentiation appears when demand suddenly outstrips available
professional numbers”; within the context of this research, the increasing diabetic
population and resultant pressure placed upon diabetes services may be viewed as
evidence of such shortages. Parallels with early medical specialisation, in
responding to the epidemic of Egyptian Opthalmia (Davidson 1996) and the effects
of war (Godber 1978, Stevens 1966) exist.
Hugman (1991, p94) refers to the development of sub-groups by a profession as
“internal closure”, as opposed to “closure through territorial claims on knowledge”
or “lateral closure” (a feature of inter-disciplinary boundary disputes). Hugman’s
internal closure encompasses the divisions of specialists from generalists within the
same profession and the development of assistant grades (assistant grades in
podiatry discussed also in sections 1.5.6.1 and 1.7.3.1). Hugman (1991) considers
internal closure to be a product of professionalisation, specialisation evolving as
professions seek to maintain or increase their status, stressing their more glamorous
roles and claiming levels of skills which match the forms of higher knowledge
associated with their profession. He refers to these as “virtuoso roles” (Hugman
48
1991, p95) – roles which provide the link between practice and theoretical
knowledge and links the pursuit of such roles to the attribution of seniority and to
career development. These virtuoso roles are considered by Hugman to be of
particular importance where the knowledge base is disputed or not fully regulated, as
they lend more weight to the argument that a given profession has the solutions for a
specific set of social problems. These facets may be highly relevant in diabetes
podiatry with its apparent lack of clearly defined specialist skills and as yet unclear
educational credentials. Hugman (1991) also points to the way in which virtuoso
roles are those associated with “curing” rather than “tending”, the latter lack social
status and so have tended to be the roles discarded by professionals, delegated along
with menial duties to assistant grades. This phenomenon can be related to the
advent of assistant grades in diabetes specialist podiatry, to the shared care model of
service provision and the stratification of clients based on the “at risk” system of the
NICE guidelines. It could be argued that the high-risk clients confer a high status
(possibly heroic) limb and lifesaving role on diabetes specialist podiatrists. That
some of the caring roles may be those which formed important elements of the
profession’s origin is recognised by Hugman (1991), within podiatry the reluctance
to accept assistant grades (Lorimer 1995, Webb et al 2004) and the strict limitation
of their scope of practice (Society of Chiropodists and Podiatrists 2006a and 2006b)
may be manifestations of concerns about delegating roles. Hugman (1991) points to
how specialty may be separated by type of practice (e.g. surgery) or, as with diabetes
podiatry in terms of service users (Hugman 1991). The hierarchy associated with
different client groups is also discussed by Hugman, work with children being
comparatively prestigious, while work with the elderly having low status and acute
(curable) problems having greater prestige than chronic (care requiring) problems.
1.7.1 Development of Specialised Practice
Abbot (1988) recognises that professional groups are not static. New professions
develop, some old professions disappear and, at any point in time, the jurisdiction
claimed by existing professions is increasing or diminishing. This is related to the
growing complexity of professional tasks which results in the emergence of
specialisations within a particular knowledge area. Using the illustration of
psychiatry, originating within medicine, Abbott considers that specialisms go on to
49
become separate units competing independently within the system of professions.
For Abbott, acquiring and controlling tasks is the key to advancing a profession. By
providing scope for interpretation, the lack of specificity contained within the NSF
for diabetes, the foot care focused points of the NICE guidelines for diabetes care
and the Scottish Intercollegiate Guidelines Network may present an opportunity for
increasing podiatric specialisation in diabetes. Freidson (1988) discusses the
important discretionary powers of practitioners over how work is done, the limits to
their power being established largely by other professionals serving as
administrators within their employing organisations. The impact of other
professions on the history of professional development is also acknowledged by
Abbott (1988), who considers such development to be driven by “interprofessional
competition”. The cause of interprofessional conflict is the need to establish
effective control over an area of work through the application of specialist abstract
knowledge by a professional group; a link which Abbott terms “jurisdiction” (1988).
The term “jurisdiction” is used to describe the profession’s effective control over a
“task area” (Abbott 1988, p112), and a classified list of tasks undertaken by a
profession at any point in time therefore maps its jurisdiction (Abbott, 1988, p43).
Within the evolution of an occupation, Dingwall (1983) discusses “occupational
coalescence” - the collecting together of tasks already within the official domain
(“fission”), which are combined with tasks new to the official domain. Dingwall
(1983) relates the formation and subsequent recognition of occupations to material
changes, arising from either alteration in the physical or social environment or in
technology. Changes in the social environment can be evidenced by a significantly
increasing diabetic population and the multi-disciplinary approach to diabetes; and
within diabetes foot care assessment and risk stratification techniques, client
education, advances in wound care and therapeutic orthoses/shoes and casting
techniques may be viewed as technological advances. Dingwall (1983), in
considering the advent of specialties within occupations, highlights the work of
Bucher and Strauss on segmentalization [sic]; where colleagues within a segment
find that their work has become too disparate for a single device to coordinate and so
split into distinct specialities. It remains unclear though whether the work of the
diabetes specialist podiatrist is disparate from that of core podiatry, for while core
50
podiatry has been evaluated (Farndon 2006) no such analysis of diabetes podiatry
has been undertaken.
1.7.1.1 Theories of Phasic Development
Early theorists, who suggested the phases through which occupations or activities
pass en-route to professional status, are highlighted by Johnson (1972). These
include Greenwood (1957) and Wilensky (1964). The approaches of these authors
are from the “trait” tradition which has been challenged (and largely discredited) by
later theorists in terms of its acceptance of professions’ own explanations of their
activities, the a-historical account of the professions and the relevance of the traits
identified (Abbott 1988, Johnson 1972). However the notion of a staged
development of specialist practice is also proposed by Zetka (2003) who points to
Bucher’s (1988) conceptual imagery illustrating the stages involved in this process
(table 15.):
Table 15. Bucher’s (1988) stages in development of specialist practice.
1) Occupational members initially organise new specialties and advance their claim to a territory.
2) Such claims are accepted by significant sponsors, allies or other publics. 3) Institutionalisation of new work roles for members, within formal organisations
are progressed.
4) On-going and standardised training programmes are established.
From: Bucher, R. (1988) On the natural history of health care occupations. Work
and occupations, 15:131–47.
Zetka (2003) relates Bucher’s stages to how occupational members initially organise
new specialties and advance their claim to control new technology. Through a
process of negotiation with the more powerful occupations with an interest in
jurisdiction and the division of labour, the new specialty seeks to legitimate their
control of the application of the new technology and the market share which the
technology makes available. The degree to which diabetes specialist podiatrists can
claim special expertise in the diagnosis, evaluation, and management of persons with
diabetic foot disease – their “new technology” is crucial in this negotiation process.
Supporting evidence of this special expertise may centre upon unique knowledge
(Durkheim 1956, Strong 1984, Abbott 1988, Freidson 1988, Leicht and Fennell
2001), skills and practices (Bucher and Stelling 1969), applied by practitioners who
51
have undergone recognised and accredited training (Bennett and Grant 2004,
Hugman 1991) and underpinned by a research evidence base (Strong 1984, Abbott
1988, Freidson 1988).
1.7.2 Unique Knowledge, Skills and Practices
In examining the expert division of labour and professional work, Leicht and Fennell
(2001) consider the status of the expert to be based on the professional’s control
over formalised knowledge systems, which confer social power to those who
produce and use knowledge. Several theorists have considered the impact of
knowledge. Durkheim (1956, p117-118) states:
“Each occupation indeed, constitutes a milieu sui generis which requires
particular aptitudes and specialized knowledge, in which certain ideas, certain practices, certain modes of viewing things, prevail… [society]
creates for itself, by means of education the specialized workers whom it needs.”
Further, Abbott (1988, p102) highlights the way in which professions:
“Expand their cognitive dominion by using abstract knowledge to annex new
areas, to define them as their own proper work”
which he considers to be a feature distinguishing professions from occupations, in
contrast the latter “fight for turf”. Central to Abbott’s argument is that a defensible
jurisdiction must be based on a coherent set of tasks anchored to a profession’s
abstract knowledge base. Further, Abbot considers that the level of abstraction is
related to the jurisdictional strength, particularly where abstract knowledge is
associated with effective treatment. The optimum level of abstraction will vary from
case to case, but will be between “the extremely general and the extremely
concrete”; the public perception of legitimacy and efficacy in each case determines
the optimal level of abstraction (Abbott 1988, p105).
Freidson (1988) examined the links between knowledge and power as they relate to
the professions. Grounding these relationships in the institutions which support and
provide the setting of professional activity, Freidson considered formal knowledge
(higher knowledge which has been formalised into theories or other abstractions
which attempt to provide systematic, reasoned explanation and justification of the
facts and activities believed to constitute the world) to be an “unstable element” in
52
the exercise of power. Unlike Foucault (O’Farrel 2005), Freidson (1988) does not
consider knowledge itself to be a system of domination, but rather that the
professions, as agents (creators and users) of knowledge are provided with
opportunities to exercise power via the institutions which sustain them (such as
professional bodies) and the institutions which offer situations where professionals
can exercise their power (usually the professional’s employer).
1.7.2.1 Training and Accreditation
Abbott (1988) points to the tendency for specialist groups to develop special
education and certification structures within their parent profession. In discussing
occupational credentialing of practitioners, Freidson (1988) highlights the monopoly
of practice (control over the supply of a service) and the opportunity to limit entry to
a profession made possible through licensing, (though for podiatrists in the UK this
takes the weaker form of registration and protection of title). Hugman (1991, p97),
in discussing internal closure points to the way in which:
“…specialisms represent the success of subgroups in marking out an area of
practice which attracts enhanced status because additional training is required, and to which access by other members of the wider professional
group can be restricted”.
However for Diabetes Specialist Podiatrists there is currently no clear educational
route to specialisation, following Hugman’s thesis this weakens their claim to
specialist status via internal closure.
For health professions state regulation is often bound up with certification (Freidson
1988, p71). Credentialing which is under the direct control of the professions,
Freidson refers to as “private occupational credentialing” – the official
acknowledgement of the candidate’s qualifications to perform a particular kind of
work competently and reliably. Such certification is particularly well developed in
areas of specialisation within medicine, and has as a prerequisite the completion of a
formal training programme associated with higher education (Freidson 1988).
Inextricably linked to occupational credentialing is the issue of accreditation for the
higher education institute at which the certificate was gained; in the UK this is the
function of the Quality Assurance Agency for Higher Education.
53
In contrast to occupational credentialing (certification of practitioners), Freidson
(1988) identifies institutional credentialing, the requirement that institutions employ
the holders of occupational certificates, as the process by which professions generate
and maintain demand for their services. Using an illustration of the requirement for
a registered nurse to be on duty at all times in an emergency room, Freidson
highlights the sheltered position within the labour-market provided for professionals
in specific positions in organisations. Development of the National Minimum Skills
Framework for Commissioning of Foot Care Services for People with Diabetes by
Foot in Diabetes UK may represent the beginnings of such institutional credentialing
in the field of diabetes podiatry.
1.7.2.2 Research
Clinical practice in diabetes foot care is considered by some commentators to be
based upon opinion rather than being research led (Jeffcoate and Harding 2003,
Young 2003b). In particular, the evidence base underpinning some clinical activities
in diabetes foot care has been criticised, notably monofilament testing, palpation of
pulses and prescription of footwear (Cavanagh 2004a), debridement and wound
management (Jeffcoate and Harding 2003, Young 2003) and therapeutic footwear
(Cavanagh 2004b).
Freidson (1988) considers that unlike the crafts, professions have been able to
control technological innovation by having their own teacher-researchers to produce
and legitimise new knowledge; and that through the continual creation of new
esoteric knowledge professions are able to avert routinisation of their expertise.
This perspective is supported by Strong (1984), who points to the vastly increased
technical power, associated wealth, prestige and influence that the embrace of
academy and of medical science has brought to the contemporary medical
profession; but also to the way in which the medical profession which has
historically derived its power partly from the charismatic role of the healer, has now
become a target for other entrepreneurial, academic professions with research
interests in healthcare.
54
1.7.3 Stratification of Roles and Functions
In discussing the dynamic nature of professional boundaries Nancarrow and
Borthwick (2005) use the exemplar of orthopaedic surgeons, highlighting the trend
for specialised occupations’ choice of lucrative, high status work while discarding
more mundane duties. The authors relate this phenomenon to Hughes’ (1958, p49)
division of labour based on “dirty work”. Further, Zetka (2003) considers that
having protected their self-defined “core” tasks, powerful and dominant
occupational groups are largely indifferent as to who controls or performs related
work activities, so long as they get done. However Nancarrow and Borthwick
(2005) consider that through the creation of assistant grades, the control of low
status work can be retained within a profession. The creation by an occupation of
such “auxiliary” occupations is considered by Bucher (1988) to be a type of
“occupational expansion”; itself a feature of occupational consolidation (activities
undertaken by an occupation in order to secure its institutional niche). Hugman
(1991, p94) refers to the development of sub-groups by a profession as “internal
closure”, as opposed to “closure through territorial claims on knowledge” or
“lateral closure” (closure sought by professions when faced with inter-disciplinary
boundary disputes). Assistant grades are a form of subordinate sub-group to whom
low status work (Hughes’ “dirty work”) can be delegated, allowing professionals to
specialise - developing high status, autonomous 'virtuoso' roles.
1.7.3.1 Implications of Role Stratification
Following the argument of Zetka (2003), in supporting the diabetes specialist
podiatrists’ claim to specialty, medically trained diabetologists may be improving
their own visibility and legitimacy of ownership over the specialty of diabetes care.
The diabetes specialist podiatrists present no threat to the diabetologists’ dominance
and may be available to undertake roles which diabetologists wish to shed. The
delegation of roles to diabetes specialist podiatrists (or diabetes specialist nurses)
may be driven in part by the working time directive. While, as illustrated by
Nancarrow and Borthwick (2005), the model of medical dominance may allow the
reclamation of such professional turf by the medical profession, drivers such as the
working time directive make this is most unlikely. The intra-professional aspect of
this form of labour division, may be that diabetes specialist podiatrists choose roles
55
with which they identify (what Zetka [2003] would call their self-defined core
tasks), while leaving the routine work for the generalist podiatrists and the low status
work for podiatry assistant grades. This may be evidenced by the clients who are
assessed as being at “low risk” of ulceration using the NICE guidelines, being
increasingly cared for by community podiatrists; by the “shared care” model where
the diabetes specialist podiatrist undertakes the specialised care, management
planning and client education, while the generalist podiatrist continues with follow
up, routine care and monitoring roles; and by the establishment of a “diabetes
specialist podiatry assistant” grade, considered by Holland et al (2002) to have a
pivotal role within secondary care. Hugman (1991, p94) highlights the ambiguous
status of assistants, for while they derive their nature from the profession with which
they are associated, they are simultaneously excluded from that profession – “being
neither entirely distinct nor entirely integrated”. Claims for effective control over
the task area of treating clients with diabetic foot disease represents what Abbott
(1998) would call the diabetes specialist podiatrist’s “jurisdiction”; a classified list
of tasks undertaken by a profession at any point in time mapping its jurisdiction
(Abbott, 1988, p41-43).
If the diabetes specialist and the generalist podiatrists both consider tasks to be part
of their core roles the potential for conflict arises. Indeed Nancarrow and Borthwick
(citing Burrage and Torstendahl 1990) point to the intra-professional conflict
between “generalists” and “specialists” which is an outcome of the way in which
professional organisations operate. Abbott (1988, p106) discusses how
specialisation is also a “strategy for upwardly mobile groups seeking to set
themselves above their current peers” – division may also be vertical rather than
horizontal – focussing on differences in status rather than task. Claims to unique
skills and practices feature in the negotiations of healthcare professionals in their
pursuit of status and power within organisations (Bucher and Stelling 1969).
1.7.3.2 Negotiating Roles
Bucher and Stelling (1969) highlight the variable (almost unique) nature of roles
negotiated by individual healthcare professionals, within the context of their specific
organisation and or team. Freidson (1988) also highlights the comparative
autonomy of professional employees and the impact this allows them to have on
56
managerial and policy issues. Such influence is constrained by the formal policies of
the employing organisation and the allocation of resources (Freidson 1988),
professionals are described as being “technically autonomous but organisationally
impotent” (Freidson 1988, p174)
1.7.3.3 A Note on Negotiated Order Theory
Negotiated order theory is considered to originate from “symbolic interactionism”
(Day and Day 1977), a term devised by Herbert Blumer in 1938 (Joas 1987) to
describe how, through processes of interaction, meaning is created and maintained in
organisations. However it was through subsequent research in the area of
professions and occupations undertaken by other sociologists from the “Chicago
School” which negotiated order theory was developed (Day and Day 1977).
Work by Anselm Strauss is considered to have laid the foundations of negotiated
order approach (Joas 1987), indeed Day and Day (1977) point to the earliest clear,
succinct theoretical statement on negotiated order, produced by Strauss et al (1963).
This describes a complex mix of goals, the (sometimes informal) division of labour,
“tacit agreements, unofficial arrangements and official decisions” (Strauss et al
1963, p164), which combine to produce order. Within a complex scenario, featuring
professional groups from different personal backgrounds, training, professional
socialisation, with varying levels of experience and perhaps most significantly
different hierarchical positions, Strauss et al (1963) identify the process of
'negotiation' - a dynamic process, involving continual reconstruction and
reproduction - as the mechanism by which order is procured. The authors highlight
the small area of action governed directly by clearly enunciated rules and the
flexibility in interpreting and applying extant rules, allowing “a maximum of
innovation and improvisation” (Strauss et al 1963, p153). While in our post-
Griffiths era, management may be more inclined to codify and direct clinical
activities, and clinicians are faced with norms and targets which direct and constrain
their activities (Leicht and Fennell 2001), there is however, frequently a lack of
specificity in national guidelines and National Service Frameworks which may
allow negotiation over their implementation.
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Strauss (1978, p5-6) describes the negotiated order of an organisation as “the sum
total of the organization's rules and policies, along with whatever agreements,
understandings, pacts, contracts, and other working arrangements currently
obtained". In this way negotiation is an ongoing process which can result in re-
constructions. The context in which negotiations take place including the number of
negotiating parties, their relative power and the number and complexity of the issues
involved, impact upon outcomes (Strauss, 1978).
1.7.4 Recognition of Specialisation
Abbott (1988, p. 59) acknowledges the need for external (social) recognition of
jurisdictional claims: “In claiming jurisdiction, a profession asks society to
recognize its cognitive structure through exclusive rights; jurisdiction has not only a
culture, but also a social structure.” Further, Abbott (1988, p. 81) recognises the
reciprocity between a profession and its work and links the macro-level claims of
professions to individual professionals in the following manner: “It is by their claims
that groups identify themselves; to claim a jurisdiction is to claim it for someone.”
Dingwall (1983) also appears to imply the need for national recognition in order for
a group to gain the status of an occupation. This need for public acceptance is also a
theme in Hugman’s (1991 p110) work, indeed the issue of “public image” is defined
as the “capacity that an occupation has to ground its claims for professionalism in
the public acceptance of its knowledge and skills”. Membership of Foot in Diabetes
UK, a national group of (predominantly podiatry) professionals who specialise in
management of the diabetic foot, may be one means to gain such national
recognition for diabetes specialist podiatrists. Young (2003a) considers that
membership of this body will give diabetic foot practitioners a voice in the process
of developing a specialist career structure, and that within the UK podiatry has not
been afforded the status it deserves (Young 2003b).
1.7.5 The Professional Project
While Abbott (1988) terms the activities of professional groups in their attempts to
advance their professional aspirations “professional projects”, it was Larson’s
(1977) in-depth, historical study of professionalisation which gave rise to the
concept of the professional project.
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A professional project can be defined as an occupation’s use of its resources to gain
a secure and formalised position within the hierarchy of professions, attain financial
rewards and social advancement (Larson 1977). Such activity is undertaken at many
levels; collectively via an organisation, for example a professional association and
individually through personal negotiation and interaction. Larson (1977) points to
the use of material and ideological resources to advance the occupation’s claims in
their drive to establish a monopoly for their services within the market. Such
resources include cognitive exclusiveness, which (echoing Jamous and Peloille
1970), Larson points out, features an element of indeterminate and untestable, tacit
knowledge – further reinforcing individual autonomy (see also section 1.7.2 Unique
knowledge and skills). Thus trust in individual professionals is solicited, in
exchange for their knowledge and internalised ethical norms (Larson 1977). This
appeal to ethical standards is necessary because advancing a profession relies upon
the establishment of what Larson calls “social credit”, in this way “fears of
professional abuse had to be overcome. For this, trust in the probity and ethicality
of the professional practitioner had to be convincingly established…” (Larson
1977, p56-57).
Institutionalised training, tested by entry examinations which are administered by
peers, links the sale of professional labour to the educational system (Larson 1977)
and the production of professional producers – usually within a university. Larson
argues that more importantly than income, claims to legitimacy and respect are
legitimised through superior education.
1.7.5.1 The professional project, Class and Politics
Larson relates the professions to the more general problems of intellectuals in a class
society, asserting that objectively and subjectively professions are outside and above
the working class. “The market of labor [sic] and services within which
professionals operate is structurally different from the labor [sic] market faced by
less qualified workers” (Larson 1977, pxvi). Larson (1977) argues that
professionalism can be viewed as an expression of class consciousness where “Self
definition and self esteem has become increasingly based on occupation” (Larson
1977, p154). As Macdonald (1995) points out, Larson’s professional project
embodies the Weberian notions of conflict and competition, professions constituting
59
interest groups vying for both economic advantage and social status, employing a
strategy of social closure. Because Larson (1977) writes from a Marxist perspective
it is perhaps unsurprising that issues of capitalism and class are also illuminated.
Building upon the work of Freidson (1975) who connected the autonomy of a
profession to the power of the state and the position of privilege which a profession
is able to secure via the influence of the elite which sponsors it; the political nature
of an occupation’s professional project has been linked by Larson (1977) and
MacDonald (1995) to the formation and nurturing of relationships with Freidson’s
strategic allies. In the case of podiatric diabetology this is manifest in the cultivation
of links with medical doctors who have established power and authority in the field
of diabetology – the importance of this relationship and influence formed a repeated
theme within the accounts of the podiatric-clinician and Faculty of Management
respondents.
While Dingwall (1983) acknowledges a possible role for class in the process of
segmentalization, Larson (1977, xiii, xiv) highlights that an emphasis on cognitive
and normative dimensions of profession
“tends to separate these special categories of the social division of labor [sic] from the class structure … emphasis on the professions’ cognitive
mastery and the implication of class neutrality place them, rather, in the stratum of educated and socially unattached intellectuals…”.
Gramsci does acknowledge the existence of an isolated group of “traditional”
intellectuals no longer bound to the ruling class, but his general position is that
intellectuals are organically tied to the class whose interests are upheld by their
work; and building upon this he identifies a role for intellectuals in challenging the
hegemonic power of the ruling class (Larson 1977).
1.8 Medical Dominance
Willis (2006) highlights state patronage and support as the basis for a “golden age”
of medical dominance which existed between the 1930s and the 1970s. Western
states being willing to leave health matters in the hands of the predominantly male,
white, middle class group which formed the medical profession of the time. Indeed
state support of medical doctors’ dominance afforded them “autonomy” - control
over the content of their own work, “sovereignty” - status as institutionalised
60
experts on all matters relating to health in the wider social arena and “authority” -
control over the work of other healthcare professionals (Willis 2006, p422).
Medical control over other healthcare professionals and specifically medical
authority over the profession of podiatry will be the focus of the following section.
1.8.1 Foundations of Medical Dominance
Abbott (1988, p1) highlighted the importance of the traditional professions in
society, they “... heal our bodies, measure our profits and save our souls” for which
they are afforded high status.
1.8.1.1 Professionalism
Professionalisation – the process through which occupations advance their claims to
professional status – has produced an expanded system of professions (Larson
1977). Within the healthcare division of labour, Freidson (1975) points to the
control over their own work and control over other professions as illustrations of
medical dominance:
“…medicine has come to dominate an elaborate division of labor [sic], and
its jurisdiction is broad and far-ranging …” (Freidson 1975, p337).
The pre-eminent position of medicine within the hierarchy of healthcare professions
is underpinned by the effects of occupational and institutional credentialing
(Freidson 1988), thus a monopoly of practice and guaranteed demand for that
practice are extant (see also sections 1.7.2.1 and 1.8.1.3).
1.8.1.2 Blending Knowledge and Mystery
The ability to produce, legitimise and disseminate new knowledge is for Freidson
(1988) the means by which routinisation of professional expertise is avoided (see
section 1.7.2.2). The knowledge base of a profession constitutes a resource which
supports its claim to monopoly jurisdiction (Freidson 1975) and founded upon the
acquisition of professional knowledge, educational credentialism is considered to be
part of the exclusionary mechanism employed by status groups (Freidson 1988,
Murphy 1988, Collins 1971). Thus the well-established, state sanctioned
mechanisms for medicine to undertake production, legitimation and dissemination of
knowledge serve to reinforce medical dominance. Jamous and Peloille (1970) also
highlight the importance of indeterminate knowledge and consider that a
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professions’ autonomy is determined by the ratio of its indeterminate and technical
knowledge.
“The I/T ratio expresses the possibility of transmitting, by means of
apprenticeship, the mastery of intellectual or material instruments used to achieve a given result … the part played in the production process by
“means” that can be mastered and communicated in the form of rules (T), in proportion to the “means” that … are attributed to the virtualities [sic] of
producers (I).” (Jamous and Peloille 1970, p112)
Such indeterminate knowledge forms part of medicine’s craft mystery which unites
the profession and allows it to derive power from the historic, charismatic role of the
healer (Strong 1984).
1.8.1.3 Closure Theory
Derived from the Weberian perspective (Murphy 1988, Macdonald 1985), the social
closure of professions is the basis for professional closure (Murphy 1988).
Stratification by status and subordination of competitors allows dominant groups to
close off opportunities to others, establishing and preserving a monopoly for the
dominant group (Weber 1978). Larson (1977) stressed the importance of control
over the market for professional services, the supply, demand and prices. In the
most marked form of closure “… opportunities for special employment grow into a
legal monopoly…” (Weber 1978, p935). Thus the ability of a professional group to
constitute and manage a market for their expertise, the maintenance of which
requires continuing dominance over allied and competing professions is central to
maintaining closure (Larson 1977). The drive to develop and subsequently maintain
such a monopoly in the market place for the skills of a particular profession involves
the creation and subsequent defence of professional jurisdictional boundaries
(Abbott 1988). The competitive environment is characterised by professions
defending and seeking to extend their own boundaries. Subordinate professions
seek to usurp or encroach upon the jurisdictions of other professions (Parkin 1979) –
most frequently those perceived to be “above” them within the hierarchy, while
dominant professions employ an exclusionary model of closure (Parkin 1979).
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Larkin (1983) points to how medical dominance became entrenched in the British
healthcare system with the inception of the NHS, taking on a formalised,
institutionalised character. Health professions such as chiropody which enjoyed a
degree of commercial and clinical autonomy were still subjected to the
“occupational imperialism” of medicine (Larkin 1983, p155), which constrained the
development of chiropody on its own terms, imposing tight restrictions and role
boundaries in exchange for professional legitimacy and recognition (Larkin 1983).
1.8.1.4 Hegemony
Boothman (2008) points to early use of the word hegemony within the Marxist
tradition as a synonym for political leadership. Later Gramsci developed the concept
of cultural hegemony, which, writing predominantly in his prison diaries, he
distinguishes from political hegemony (Boothman 2008, Anderson 1976). Anderson
(1976) highlights the difficulties of censorship and atrocious prison conditions faced
by Gramsci, which make his work particularly challenging to interpret with
accuracy.
Cultural hegemony emphasises consent rather than coercion (Boothman 2008,
Femia 1981, Anderson 1976), the use of force being linked to dictatorship rather
than hegemony (Anderson 1976). Femia (1981) explains that while social control
can be affected externally through reward and punishment, it can also be achieved
internally “by moulding personal convictions into a replica of prevailing norms”
(Femia 1981, p24). Thus maintenance of the status quo involves the dominant class
or group developing a consensus culture (Ives 1988) where those subjected to
domination identify their own best interest as being the same as that of the dominant
group (Femia 1981). A hegemonic culture exists where a dominant class or group is
able to exert social control, maintain social leadership and impose their ideologies
(values and world view) (Boothman 2008, Ives 1988), which the dominated class or
group accept because it is considered to be legitimate (Femia 1981) natural, normal
and to represent common sense (Ives 1988).
1.8.2 Medical Dominance, Declining or Changing?
The dynamic nature of hierarchical relationships between the professions working in
63
health care is a common theme amongst authors who focus on this area. There is
however disagreement regarding the drivers for change and whether medical
dominance is a declining or changing phenomenon.
1.8.2.1 The Case for Declining Medical Dominance
Theories of declining medical dominance have been couched in various terms.
Haug (1988) considers that deprofessionalisation, characterised by declining
professional legitimacy and reduced monopoly over knowledge is the outcome of a
more informed and less deferential public. Oppenheimer (1973) and McKinlay and
Stoeckle (1988) describe a process of proletarianisation, where partly as a
consequence of being employees rather than retaining self-employed status, medical
doctors lose control over the location and content of their own work. In contrast to
Freidson’s (1994) interpretation, Coburn et al (1997) consider restratification as the
means by which medical institutions are co-opted and used by external forces to
constrain their own members. Under the influence of “neo-liberalism” Willis (2006,
p424) cites an extension of anti-trade union strategies to the professional labour
market - which tip the balance of power from labour towards capital - as the main
driver for a general decline in medical dominance.
Coburn et al (1997) and Willis (2003) consider that medicine is a normal
occupation, subject to the same processes of industrialization, bureaucratization,
corporatization and rationalization as other occupations. The introduction into the
NHS of general management in 1984 followed in 1991 by the introduction of the
‘internal market’ brought with them new organisational structures in which rank-
and-file physicians became formally subordinate to managers (Harrison and
Dowswell 2002). Indeed since the inception of general management in the NHS,
health service managers, acting as agents of the state, have exerted bureaucratic
control over medical doctors.
1.8.2.2 The Case for Changing Medical Dominance
Proletarianisation of the healthcare workforce is rejected by Freidson (1988, 1994)
and Murphy (1990). Elston (1991) who points to extensive criticisms of a thesis of
proletarianisation (poorly defined and supported by weak, ambiguous evidence) as
applied to healthcare professions and specifically medicine, concludes that theories
64
of diminishing medical power are not satisfactorily developed or amenable to
rigorous testing.
Though acknowledging that medical governance has changed Allsop (2006), Dent
(2006), Sheaff et al (2003) and Freidson (1994) all point to increased diversity and
reconfiguration as the means by which the medical profession is retaining authority
in the face of significant challenges. Freidson (1994, pp9, 121, 144-6) asserts that
medicine is undergoing “restratification” to emerge in a more hierarchical form;
individual autonomy may be attenuated but the corporate autonomy and dominance
of medicine remains intact. Sheaff et al (2003) consider that this restratification
constitutes a form of subtle or “soft” governance of the English medical profession
where general (lay) managers influence most doctors not directly but by proxy. The
proxies are doctors - local professional leaders who act as a 'boundary' stratum,
communicating managerial imperatives and priorities from lay managers to their
fellow-professionals while attempting to conserve a degree of autonomy for their
profession (Sheaff et al 2003), this interface role for a boundary stratum between lay
managers and clinicians is widely applied within other health professions. At the
national level the governing body for medical doctors - the General Medical Council
(GMC) has adopted a more managerial stance in response to reduced patient
confidence and state challenges (Allsop 2006, Dent 2006). Indeed the regulatory
state in the UK has been a major influence in changing (but not removing) medical
dominance (Allsop 2006, Dent 2006). Multiple health policy reforms have
constrained medical autonomy; from the application of internal market principles in
the early 1990s (Allsop 2006, Dent 2006, Harrison and Dowswell 2002), the drive
for a primary-care led service - via the NHS plan 2000 (Allsop 2006) to the
emphasis on performance management with its attendant targets, inspections and
national clinical standards (Allsop 2006, Dent 2006, Harrison and Dowswell 2002)
manifest within diabetology through the National Service Framework for diabetes
and NICE guidelines. However a high value is still placed on medical knowledge
and skills (Allsop 2006, Dent 2006) and doctors retain a unique bargaining position
in matters of remuneration (Allsop 2006).
65
1.8.3 Podiatry and Medical Authority
The degree to which medical authority exerts a controlling influence over podiatry
appears to have changed over time. Medicine’s authority over podiatry has been
challenged – with significant repercussions.
1.8.3.1 Governance
Securing statutory registration is a major professionalisation strategy employed by
emerging occupations, an attempt to secure and maintain social closure (Macdonald
1985) which confers the state-legitimised right to practice in a given field (Willis
2006, Freidson 1994) and forms a representation of power and authority (Bucher and
Strauss 1961). Indeed Macdonald (1985, p541) points out that “Many occupations
have seen registration as a keystone which would lock into position, once and for
all, their often shaky structure of norms, practices, rights – and privileges.”
Historically the medical profession has exerted dominance in the area of health care
by restricting the occupational territory of health professionals through medical
membership of their registration bodies (Willis 2006, Freidson 1994). While the
Health Professions Council (HPC) - the UK governing body for podiatry - has no
medical representative on its council, the Health Professions Order 2001 requires
that the HPC’s Fitness to Practise Committees (Health, Investigating and Conduct
and Competence) have at least one registered medical practitioner on each
committee (HPC 2009a). Medical practitioners may also act as HPC “panel
members”, a panel being convened to decide on how a complaint against an HPC
registrant should be dealt with (HPC 2009b). Thus while the authority of medicine
over podiatric governance may be reduced, it is still extant.
1.8.3.2 Collaborative Healthcare Teams and Medical Dominance
Collaborative models in which health care is provided by multi-disciplinary teams
have become established in Britain. Here podiatric specialisation in diabetes has
become inextricably linked to working within an inter-disciplinary team (see 5.3.1
Drivers for specialisation in diabetes podiatry). Bourgeault and Mulvale (2006)
highlight that while the boundary blurring effect of overlapping clinical roles in such
teams should act as a curb on medical dominance; it is in fact having no effect, such
is the “structural embeddedness” of medical dominance. Indeed Long et al (2006),
point to how enculturated behaviours privilege and perpetuate medical dominance
66
within the multi-disciplinary team, working to suppress the voices of other specialist
clinicians within the team: “Medical dominance … works against multi-vocality in
decision making within multidisciplinary clinical teams.” (Long et al 2006, p506).
The comparatively high value placed upon medical doctor’s time and the enhanced
authority assigned to doctors in such areas as admission and prescribing rights
continue to act as barriers to democracy within the multi-disciplinary team (Long et
al 2006).
1.8.3.3 Podiatric Challenges to Medical Authority
The potency of medical authority over podiatry has been tested by the podiatric
surgeons (see section 5.2 The establishment of podiatric surgery). Following their
direct challenge to the sole rights of orthopaedic surgeons to undertake invasive foot
surgery in the NHS and against the wishes of medical doctors, the Podiatry
Association established podiatric surgery as a safe and effective competitor
(Borthwick 1999, 2000). Health policy of the day played an important role. The
Conservative government fundamentally opposed to monopolies (Webster 2002)
and seeking a solution to long waiting lists was receptive to the arguments of the
podiatric surgeons; who in affording accessibility, effectiveness and cost
effectiveness in foot surgery met all the criteria set out in the Griffiths report. Such
congruence may represent a manifestation of Weber’s elective affinity (Howe 1978).
1.8.3.4 The Legacy of Challenging Medical Authority
As Borthwick (1999) pointed out, mounting such a direct challenge to medical
authority guaranteed a hostile response (see section 5.2 The establishment of
podiatric surgery). Within the UK a state of near enmity between some orthopaedic
surgeons and podiatrists is now extant - as evidenced by the recent Times article by
one eminent orthopaedic surgeon and the responses to it:
“Invariably, the right person [to treat foot pain] is an orthopaedic surgeon
specialising in foot and ankle surgery, but people tend to think first of podiatrists and chiropodists (two names for the same profession). They don't
have a medical background or the experience to look at the complexity of the foot in relationship to the rest of the body. That is fine if you want a corn
removed, but they often don't get to the cause of the corn.” (Davies 2009)
This article drew a measured response from the Society of Chiropodists and
Podiatrists:
67
“We read with some disappointment the article "Doctor, Doctor: foot pain that won't go away". It is misleading, at best, to suggest that chiropodists /
podiatrists are not skilled in considering the cause of corns. Podiatrists (and chiropodists) undergo extensive training in the assessment, diagnosis and
management of foot pathology and its relationship to systemic disease.” (Brown 2009).
However on an international podiatry website, the online responses of some
podiatrists were more vociferous (though interestingly one podiatrist elects to use a
pseudonym):
“Podiatric surgeons UK, seems your time is drawing to a close. Game over; they (FRCS) really do want their balls back, and I've no doubt they'll
castrate you to get them, shame that we'll all get caught up in the process.” (Spooner 2009).
“Heaven forbid we go back to the bad old days of outrageously poor quality
orthopaedic foot surgery without any other alternative for patients who require some degree of understanding of foot function to fix their
problem...let alone letting the public think we don't understand what causes a corn!” (Lucky Lisfrank 2009)
“Not surprised at all. I work as a Podiatrist in the NHS in the West of
Scotland and occasionally [sic] have patients come back for replacement orthotics because they have been to see an ortho [sic] surgeon who has
thrown thier [sic] orthotics in the bin because "they are useless".......then paitients [sic] pain returns as the don't have their orthotics and frantically
call for an urgent appointment to get new ones!!!” (Barrie 2009).
1.8.4 Conclusion
Medical authority over other health professions is still extant. However such
dominance is not a fixed entity; it is open to challenge, subject to political, social
and educational influences and appears to be less potent now than during the
“golden age of medical dominance” described by Willis (2006, p442).
Diabetes podiatrists, unlike podiatric surgeons appear to be utilising the support and
patronage of senior and well placed medical practitioners to increase their scope of
practice and advance their claim to enhanced status within podiatry and the wider
healthcare workforce (see section 4.2, 4.5, 4.7.2 and 4.9). Medical doctors in turn
appear to be utilising diabetes podiatrists as a group willing and able to undertake
tasks which medicine needs to shed (see sections 1.7.3.1 Implications of role
stratification and 4.3 Change over time), but over which it prefers to retain some
degree of control. Effectively both groups have a vested interest in the development
68
and legitimation of diabetes podiatry, guaranteeing the continued support of both
parties. Should this convergence be disturbed however – for example through a
challenge to the authority of medicine over diabetes podiatry – the situation may yet
change.
1.9 Legal Implications of Specialisation
Freidson (1988 p104-105) states that “the specialist or expert poses a serious
problem to the law” and that such occupations are “held liable for negligence by a
standard more strict than that applied to the actions of other, ordinary people”.
However determination of the higher standard required from specialists “must rely in
a large part on testimony from members of that specialized occupation itself”
(Freidson 1988, p 106), a principle applied under British law using the Bolam Test
(Montgomery 2003, Jones 2000). Smith (1998) highlights the words of Caroline
Elliott (registered nurse and barrister at law) “if you describe yourself as a specialist,
the expectations of employers and patients are higher and the law demands higher
standards of care from you”. Further, Elliott advises that the law expects specialists
to be up to date and that if a practitioner acts like a doctor, they will be judged like
one in law. In discussing malpractice litigation (where a patient alleges that they
were improperly treated), Montgomery (2003) highlights the different standards of
care considered acceptable for general practitioners as opposed to specialists: failure
to make an accurate diagnosis by the former may not be negligent, while the same
error by the latter in the same patient would be unacceptable. Members of specialist
units will also be expected to display greater skills than someone in an equivalent
post in a general setting (Montgomery 2003). The standard of care follows from the
category of skills that the practitioner professes and also the position held by the
professional (Montgomery 2003). In this way by including “specialist” within their
title, by asserting specialty in the area of diabetic foot disease, by accepting a post as
a diabetes specialist podiatrist, or a post within a specialist diabetes foot care team,
the practitioners’ standards of care and level of expertise (within the specialty)
considered legally acceptable become higher than those expected of the generalist
(or community) podiatrist. Thus, under the law podiatrists can be held to account
for their specialist roles, titles and posts.
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1.9.1 The Law, Specialist Resources and Commissioning of Specialist Services
Within diabetes foot care the need for urgent intervention and follow-up of high-risk
cases is accepted as normal working practice (Larson et al 2008, Bending and Foster
2004, Holstein et al 2000, Mayfield et al 1998, Edmonds et al 1986) with risk
assessment and screening to facilitate early identification of problems clearly
highlighted in the guidelines (National Institute for Health and Clinical
Effectiveness 2004, Scottish Intercollegiate Guidelines Network 2002). However
even in locations where a foot service has existed for many years, there can be a lack
of formal planning in service growth and development (Burden 1999). It is noted
that “high risk” foot care services are resource hungry in terms of human and
financial costs (McGill et al 2003), presenting significant challenges to clinicians
seeking to provide services. Holland et al (2002) reported that additional resources
were not forthcoming to enable practitioners to provide an adequate service, citing
reluctance within primary care to cover the cost of the monofilaments required in
performing baseline foot assessments. Montgomery (2003) notes that arguments
concerning negligence due to inadequate resources may become an increasingly
important issue, as NHS purchasers make decisions concerning the levels of
resources they are prepared to commit to services, restricting the ability of providers
to choose the models of care they wish to offer. The courts have however remained
unwilling to become involved in debates over resources in the context of access to
care (Montgomery 2003). Commissioning of generalist as opposed to specialist
services may offer a provider the opportunity to argue that limited resources lowered
the standard of care and made the standards of a specialised unit unattainable
(Montgomery 2003), meaning that the terms under which care is commissioned
(generalist or specialist) has a significant effect upon fixing the standards of care.
1.9.2 The Law and Community Based Diabetes Specialist Podiatry.
Advanced podiatrists working in the community care for a predominantly medium to
high risk diabetic population (Holland et al 2002). The dangers of high-risk diabetic
patients being treated in isolation by community podiatrists, who are then frequently
blamed for causing amputations, are highlighted by Bending and Foster (2004).
These authors consider that additional training in management of the diabetic foot,
contact with the local multidisciplinary diabetes foot clinic, identification of at risk
patients, improved practitioner–client communication (acknowledging the
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“understanding gap” and with verbal communication supplemented by easily
understood written information), and improved practitioner–GP communication to
be the major ways in which litigation may be reduced. Additionally Bending and
Foster (2004) highlight that community podiatrists should not “hold on to” any
diabetic patient with a foot ulcer for too long, citing the evidence–based guidelines
for management of patients with type 2 diabetes which specify that patients with a
new ulcer, discolouration or pain in a foot should be referred to a specialist team
within 24 hours. Such guidelines form what is known as quasi-law (Montgomery
2003) and while not strictly legally binding may have some legal force, in practice
they determine the way in which people should act. Improved record keeping with
use of photographs for medico-legal purposes is also suggested by Bending and
Foster (2004).
1.9.3 The Law and Diabetes Specialist Podiatrists Working in Multi-
Disciplinary Teams
McInnes (2004) highlights that compliance with the NICE guideline 10 “care of
people with foot ulcers” section 1.1.6 (which represents a form of quasi-law
[Montgomery 2003]) is dependent upon the existence of a recognised
multidisciplinary foot care team. As Young (2003) points out [medical] consultants
are still considered to be the leaders of these diabetes teams. While consultants take
overall responsibility for patients’ medical care, their liability under the law extends
only to their own roles, actions and mistakes, and for ensuring adequate
communication; English courts having rejected the “captain of the ship” doctrine
(Montgomery 2003). Thus membership of a multi-disciplinary team, even when led
by a consultant diabetologist provides no protection for diabetes specialist
podiatrists, who remain solely responsible for their own actions. Indeed it could be
argued that membership of a mixed profession team increases the responsibility of
each team member. Professionals are entitled to rely upon the expertise of their
colleagues only where they believe the colleagues’ decisions and instructions
regarding patient care to be correct (Montgomery 2003), conferring a quasi-
monitoring role on team members. Even where professionals have separate, if
sometimes overlapping roles, they must challenge the decision of another member of
the team if this decision appears to be wrong, and must not follow instructions which
are “manifestly wrong” (Montgomery 2003). It is recognised by the courts that
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junior staff may meet the standards required of them by acknowledging their
inexperience, asking an experienced practitioner to check what they have done, and
that inexperienced practitioners may rely upon the clinical judgement of senior
colleagues, even where they suspect this to be wrong (Montgomery 2003) – clearly
neither scenario would provide protection for a practitioner claiming specialist
status.
1.10 Charismatic Authority
Max Weber, one of the founding theorists of the discipline of sociology, devised an
explanatory conceptual framework to aid the understanding of social action in
individuals and organisations. Within this framework he considered three forms of
authority to be extant. The centrality of Weber’s concept of charismatic authority to
the development and contemporary face of specialist practice is illustrated by the
data; illuminating the way in which a defined specialty was created and
disseminated, in the absence of codified or credentialed authority. Thus it represents
a guiding theoretical concept within the author’s thesis.
1.10.1 The Concept of Charisma and its Early Origins
Smith (1998) points to the earliest origins of the notion of charisma, which he asserts
began with the apostle Paul who was said to be “blessed with one of the many gifts
of the Holy Spirit, the so-called charismata”. Corinthians 1, chapter 12 lists the
number and variety of these spiritual gifts or “charismata”, which is a distinctively
Pauline term (Warfield 2001). The establishment of the concept of charisma as a
form of authority, is attributed to Rudolf Sohm published in his Kirchenrecht of
1892 (Smith 1998, Weber 1978, Weber 1968). For the Lutheran Sohm charisma
remained a spiritual fact, literally a “gift of grace” charis from the Greek, meaning
grace, while the suffix ma meaning given (Smith 1998).
From these early theological roots, Weber (1978) developed the concept of charisma
further - though still retaining Sohm’s religious language. Weber perceived
explanations relying on single, overarching forces such as Adam Smith’s laws of the
market and Karl Marx’s class conflict as the out-dated residue of antiquated world-
views, permeated by religious and quasi-religious ideas (Kalberg 2003). For Weber
interpretive understanding of the actions and beliefs of people and multicausal
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modes of explanation were the key to understanding society (Scaff 2008, Kalberg
2005). For Weber therefore charisma was not a divine God-given gift (Shils 1965),
as careful reading of his definition reveals.
1.10.2 Authority
Some confusion exists regarding the Weberian notion “Herrshcaft” which has been
translated as both “authority” and “domination”. This derives from the ambiguous
nature of “Herrschaft” – which as Kalberg (2005) notes, implies an element of force
and domination, combined with legitimacy, but for which no exact English
translation exists. In English texts it has in the main been translated as “authority”
and this is the term used by this author.
For Weber authority implies the probability that a defined group of individuals (as a
result of a variety of motives) will orientate their social action towards giving
directives or commands and that another definable group will orientate their social
action towards obedience (Kalberg 2005). Weber developed a tripartite
classification of authority (table 16.), the legitimacy of claims to authority based on
traditional, rational-legal or charismatic grounds.
Table 16. Weber’s three pure types of authority.
Rational grounds – resting on a belief in the legality of enacted rules and the right of those elevated to authority under such rules to issue commands (legal authority).
Traditional grounds – resting on an established belief in the sanctity of immemorial
traditions and the legitimacy of those exercising authority under them (traditional authority)
Charismatic grounds – resting on devotion to the exceptional sanctity, heroism or
exemplary character of an individual person, and of the normative patterns of order
revealed or ordained by him (charismatic authority).
From Weber, M. (1978) Economy and Society, Berkeley, University of California
Press, p215.
In the absence of any formalised, accredited educational preparation for
specialisation in diabetes podiatry or an established career pathway - the authority
legitimating specialised podiatry practice in diabetes is unlikely to be either legal or
traditional.
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1.10.3 Charismatic Authority
Weber defined charisma as:
"a certain quality of an individual personality, by virtue of which he is set
apart from ordinary men and treated as endowed with supernatural, superhuman, or at least specifically exceptional powers or qualities. These
are such as are not accessible to the ordinary person, but are regarded as of divine origin or as exemplary, and on the basis of them the individual
concerned is treated as a leader” (Weber 1968, p46).
Charismatic authority is not bound or supported by legal codes and statutes (Weber
1968). Assertions made by the leader and directions issued by him are accepted and
followed, not because they are necessarily perceived as being correct or legal
(rational) or adhere to what has always been done (traditional), but because the
assertion or direction is made or issued by the leader and is imbued with the leader’s
authority.
For Weber the charismatic leader represents a revolutionary force (Weber 1968),
able to inspire others, lead change and surge through existing rules (Giddens 1971).
A reciprocal relationship exists between leader and the led, the former able to
motivate and lead - the latter in giving or withholding recognition of the leader able
to bestow or withhold legitimacy:
“It is recognition on the part of those subject to authority which is decisive for the validity of charisma.” (Weber 1968, p49)
“…the basis of every authority, and correspondingly every kind of
willingness to obey, is a belief, a belief by virtue of which persons exercising authority are lent prestige” (Weber 1978, p263).
Indeed Weber (1968) points out that the charismatic’s claim breaks down if his
mission is not recognised by those to whom he feels he has been sent – he is only
their “master” if they recognise him:
“The only basis of legitimacy for it [charismatic authority] is personal charisma, so long as it is proved …” (Weber 1968, p52)
For Weber then charisma is a form of authority bestowed upon those who are
perceived to have exceptional powers and qualities (Smith 1998, Steyrer 1998,
Weber 1968, Shils 1965), a social force (Smith 1998) rather than a divine gift.
Weber insists that much more than power (“the likelihood that one person in a
social relationship will be able, even despite resistance, to carry out his own will”)
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is involved in establishing legitimate authority, for this relies upon the belief that the
authority is justified (Giddens 1971, Kalberg 2005).
For the followers or “disciples” motives for compliance can be diverse, ranging from
habit to a purely rational calculation of advantage:
“Hence every genuine form of domination implies a minimum of voluntary compliance, that is an interest (based on ulterior motives or genuine
acceptance) in obedience.” (Weber 1978, p212).
“Under certain circumstances, the charismatic chief can be different from the traditional one.” (Weber 1978, p263)
“…entirely pure charismatic authority, including the hereditary charismatic
type, etc., is rare” (Weber 1978, p263)
A reciprocal influence between context and charismatic qualities has been described
by scholars who focus on Weber’s work. Eisenstadt (1968) stresses that different
institutional spheres and social settings require differing charismatic qualities to
address problems and situations which arise within them; while Kalberg (2005)
considers that even charismatic leaders who move history by the sheer force of their
personalities do so in Weber’s interpretive sociology only if supported by facilitating
contexts. In the development of diabetes podiatry, incorporation into the multi-
disciplinary team and medical patronage, combined with current health policy and
the aspirations of diabetes podiatrists may represent such facilitating contexts.
Howe (1978) also discusses Weber’s chosen, elective affinities or
“wahlverwandtschaft” where congruence exists in the desired outcomes of different
parties or institutions, who in the pursuit of such outcomes form what is essentially a
concordance of convenience.
1.10.4 Dissemination and Discipleship
Throughout his discussion of charisma, Weber emphasises the existence of the
charismatic group or band (Eisenstadt 1968). In considering these followers of
charismatic leaders, Weber continued the use of theological language and imagery:
“[Following the charismatic leader] glorified the loyal worker who did not
seek acquisition, but lived according to the apostolic model, and was thus endowed with the charisma of the disciple” (Weber 2001).
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Where a corporate group is subject to charismatic authority Weber (1968)
highlighted the existence of an underpinning communal relationship (“Gemeinde”);
members of the corporate group being chosen on the basis of their charismatic
qualities. Shils (1965) points to the dispersed (though unequal) nature of
charismatic authority throughout the hierarchy of roles within such groups and to the
existence of attenuated forms of charisma in a number of individuals.
In discussing charisma in relation to crowd psychology Lindholm (1992) points to
the infectious nature of the charismatic’s enhanced emotionality and vitality which is
communicated to the audience. Professional conferences, teaching opportunities and
team meetings may represent such an opportunity for diabetes podiatrists to
disseminate ideas and practices and recruit “disciples”.
1.10.5 Fragility of Charismatic Forms of Authority
Because charismatic authority rests almost entirely on the leader it is idiosyncratic
and often without formal organisation (Weber 1968). The only source of legitimacy
for charismatic authority derives from personal strength which is constantly being
proved (Weber 1968). This means that the perceived legitimacy upon which
charismatic authority rests can be damaged by loss of the leader’s charisma, absence
of the leader for any reason or weakening of loyalty in the followers. Thus
charismatic authority tends to be a particularly unstable form of authority (Weber
1978).
1.10.6 Succession
On departure of the charismatic leader a replacement is required if an organisation
based on charismatic authority is to continue (Ritzer and Douglas 2004, Eisenstadt
1968). Giddens (1971) points to how successors can be hereditary or appointed.
Successors can be designated by the existing charismatic leader, or appointed by
their disciples who share their charisma; or where charisma is viewed to be
hereditary an heir will take up leadership (Weber 1968).
1.10.7 Routinisation
Routinisation is required in order to achieve permanence. In order to form any sort
of stable community of disciplines or band of followers or any sort of organisation it
is necessary for the character of charismatic authority to become radically changed.
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This is achieved through the process of routinisation - becoming either
traditionalised or rationalised (Weber 1968). Once routinisation is underway,
charismatic authority is en-route to becoming either rational-legal (rationalised) or
traditional (traditionalised) (Ritzer and Douglas 2004).
Giddens (1971) points to how routinisation requires that administrative activity be placed
on a regular basis; achieved through the formation of either traditional norms or
legal rules. The process of routinisation of charisma may differ greatly among
different institutional settings (Eisenstadt 1968). The type of authority relationship
which emerges during routinisation depends largely on how the problem of
succession is resolved (Giddens 1971). If either hereditary or appointed leaders
succeed a traditional status group is formed (Weber 1968). Where leadership
becomes linked to qualifications, a rational-legal type of authority tends to emerge
(Weber 1968), featuring salaried positions as part of the organisational economic
arrangements (Giddens 1971). Weber (1968) highlights the economic implications
of routinisation, for charisma to be changed into a permanent routine structure it is
necessary that its anti-economic character is altered. Indeed, in the long term the
majority of “disciples” will make their living out of their calling (Weber 1968).
Allied to this disciples may set up norms for recruitment involving training or tests
or eligibility. However Weber (1968) maintains that charisma itself cannot be
learned or taught, only awakened or tested. It is only where charismatic authority
becomes transmuted into routine or traditional authority and is thus no longer a
personal force that it can be regarded as something that can be taught, learned and
linked to a process of education (Giddens 1971).
Charismatic authority which has evolved in the context of boundaries set by
traditional or rational-legal authority tends to challenge the traditional and rational-
legal forms of authority. However, the constant challenge that charismatic authority
presents to a particular society will eventually subside as it becomes routinised and
is incorporated into that society.
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2.0 METHODOLOGY
Fig. 1. Methodological Overview
2.1 Philosophy
Philosophical views are inextricably bound to the research process. A basic belief
system or worldview known as a paradigm (Patton 2005, Guba and Lincoln 1994),
Literature Review
Orientated the work within the sociology of the professions
Concept Analysis Highlighted the immaturity of and need to clarify the concept “diabetes
specialist podiatry” leading to the main research question and related sub-questions
Research Questions: What does specialisation in diabetes podiatry mean?
How did diabetes evolve as a podiatric specialty? What is the impact of specialist titles?
What does specialisation in diabetes podiatry mean for services and the profession of podiatry?
Is specialisation in diabetes podiatry sustainable?
Purposive sampling
Focus group and key actor interviews Verbatim transcription and line-by-line coding
Thematic analysis, use of Verstehen and constant comparison
Triangulation
Content analysis utilising historical documents
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guides the researcher not only in choices of method, but in ontologically and
epistemologically fundamental ways (Guba and Lincoln 1994). Three key,
interconnected questions (summarised below) are highlighted by Guba and Lincoln
(1994)
1. The ontological question – what is the form and nature of reality and,
therefore what can be known about it?
2. The epistemological question – what is the nature of the relationship between
the researcher and what can be known?
3. The methodological question – how can the researcher discover what they
believe can be known?
2.2 Concepts
Strauss and Corbin (1998, p101) state concisely that concepts are considered to be
“the building blocks of theory”, while Polit and Beck bring to our attention the less
formal “conceptual model” (framework or scheme) which is a way of organising
phenomena (Polit and Beck 2004, p115). A conceptual model is formed by
interrelated concepts or abstractions assembled together in a rational scheme by
virtue of their relevance to a common theme (Polit and Beck 2004).
2.2.1 Analysing Concepts – the Philosophical Background
Defining concepts as “labelled phenomena” Strauss and Corbin assert that “science
could not exist without concepts” (Strauss and Corbin 1998, p102, 103). In the act
of naming phenomena, attention is fixed upon them; and in facilitating the formation
of hypotheses and propositions, concepts suggest how phenomena may be related to
one another (Strauss and Corbin 1998). This link between science and concepts has
been expressed by several philosophers:
Kant asserted that a priori concepts (pure concepts or categories) were the means by
which the objects of experience are ordered (Janaway 1989) and a posteriori
concepts the product of experience (Janaway 1989). For Kant empirical knowledge
requires both intuition and concepts (Janaway 1989).
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Mill (1846, p383) pointed to the role of “general concepts” (ideas or mental
conceptions) in the process of induction in what he called “operations subsidiary to
induction”, stating that “induction could not go on without general conceptions”
(Mill 1846, p390). Schopenhauer considered reason to be the capacity to operate
with concepts (Janaway 1989, p51) which he termed “abstract representations”
(Janaway 1989, p135).
Many diverse philosophical accounts attempt to explain the nature of concepts.
Common to these philosophies is that concepts are bearers of meaning rather than
agents of meaning. In this way a concept is independent of language and can be
translated. Translation is possible because the words (or agents of meaning) used in
other languages express the same concept (for example the concepts “clinician” or
“hope” are not unique to English). Rodgers (2000, p11) points to the way in which
the philosophical foundations of concept analysis and development can be divided
into two broad perspectives, the entity and dispositional theories of concepts. Entity
theories of concepts are characterised by a view of concepts as specific things,
considering each manifestation of the concept in the same way and thus failing to
account for differences within concepts; while dispositional theories present
concepts as habits or capabilities for certain behaviours (Rodgers 2000, p11).
2.3 Concept Analysis (clarification, development)
Polit and Beck (2004, p31) point to the inadequacy of dictionary definitions in
explaining concepts, which they consider to be “abstractions of observable
phenomena”. They consider that a conceptual definition presents the abstract or
theoretical meaning of the concepts being studied. These conceptual definitions are
based on theoretical formulations, on a firm understanding of the relevant literature,
or on researchers’ clinical experience – or a combination of these (Polit and Beck
2004).
Techniques employed in concept analysis have changed over time. There is now
considerable variation in methods and rationale; at the time of writing several
models of concept analysis and concept development are extant. Beginning with the
earliest documented model, the following sections explore the origins, methods,
perspectives, emphasis, critiques and use of the different models.
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2.3.1 The Origins of Concept Analysis
The practice of concept analysis is widely attributed to John Wilson. However
Wilson makes clear reference to the existence of concept analysis before his 1963
text, highlighting that the techniques employed in concept analysis are derived from
the “Linguistic Philosophy” practiced at Oxford and Cambridge (and other British
and American universities) in the thirty or so years preceding his 1963 book.
Wilson (1963) describes “the analysis of concepts” as a specialised technique
designed to handle and clarify concepts. He asserts that conceptual analysis is a
specialised subject in its own right, with its own techniques and that questions
involving abstract concepts, cannot be tackled without these techniques “in any but
the most feeble and confused manner”. He considers that conceptual questions tend
to be about meaning and as such are inextricably linked to context (Wilson 1963).
Conceptual analysis involves the significance of words (Wilson 1963,), the richness
of use and meaning (Wilson 1963) and is a sophisticated form of communication
(Wilson 1963); it is important to distinguish between the primary and central uses of
a concept and derived or borderline uses (Wilson 1963). Use and understanding of
language act both as guides to forming concepts and as tests of concepts when
formed (Wilson 1963), the best possible guide being the logical range of the word
with which the concept is normally associated, seeking the justification for the uses
of such a word is in fact analysis of the concept to which it pertains. Wilson (1963)
highlights the use of model cases in identifying the “essential features” of a concept,
the use of contrary cases to evaluate the circumstances which impact upon the
concept (Wilson 1963), the use of related cases to identify and illuminate
relationships between concepts and the use of borderline cases, which by identifying
what is odd about the borderline case clarifies what the central criteria of the case
really are (Wilson 1963). Wilson’s use of invented cases (Wilson 1963) has
however been heavily criticised by Weaver (2005) who points out building
knowledge through the use of fabricated cases (particularly where an extensive
volume of literature describing a concept is available) may be harmful.
2.3.2 Development, Change Over Time and Models of Concept Analysis
As an analytical method concept analysis has not been static. Differing underpinning
philosophical perspectives have prompted a range of techniques. Some techniques
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have been criticised for being procedural, lacking engagement with a true analytical
process. Morse (2000) acknowledges that systematic approaches to concept analysis
do little justice to the depth of inquiry or the cognitive processes involved, instead
her model of concept analysis suggests guiding principles, to be used with
thoughtfulness and if necessary added to or deviated from. The following section
traces the development of concept analysis, exploring the various models.
2.3.2.1 Norris
Norris (1982) developed a model of concept clarification (table 17.) in an attempt to
assign meaningful definitions to many of the phenomena occurring in nursing.
Norris (1982, p11) considered that concept clarification should be done within the
framework of exploratory and descriptive research, which is hypothesis and theory
generating, in contrast to deductive research, which tests hypotheses and theories.
Defining concepts as “abstractions of concrete events” and “ways of perceiving
phenomena”, Norris (like Chinn and Kramer 1995) highlights the different degrees
of abstractness presented by different concepts.
Table 17. Norris’ (1982) model of concept clarification
1. After identifying the concept of interest, observe and describe the
phenomenon repeatedly and if possible, describe the phenomenon from the point of view of other disciplines.
2. Systematise the observations and descriptions. 3. Derive an operational definition of the concept under study.
4. Produce a model of the concept that includes all its component parts.
5. Formulate hypotheses.
Derived from: Norris, C.M. (1982) Concept clarification: an overview. In Norris,
C.M. (Ed.) Concept Clarification in Nursing, Aspen, Rockville, pp. 11–19.
2.3.2.2 Chinn and Jacobs
Chinn and Jacobs first described their approach to concept analysis (table 18.) in
1983 (Knafl and Deatrick 2000).
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Table 18. Chinn and Jacobs’ (1983) model of concept clarification
1. Identify concept 2. Specify aims
3. Examine definitions 4. Construct cases
5. Test cases
6. Formulate criteria
From Knafl, K.A. and Deatrick, J.A. (2000) Knowledge Synthesis and Concept Development in Nursing. In Rodgers, B.L. and Knafl, K.A. (Eds.), Concept
Development in Nursing Saunders, Philadelphia, p44.
Based upon Wilson’s work, this model – later refined and updated by Chinn and
Kramer (1995) – also relies upon the development of cases – model, contrary,
related and borderline (Chinn and Kramer 1995). These cases and information from
a selective review of the literature are used to identify the “defining criteria” of the
concept (Chinn and Kramer 1995, p88-90).
2.3.2.3 Chinn and Kramer
Additional sources of information were acknowledged as important and enriching in
Chinn and Kramer’s fourth (1995) edition, including visual images, popular and
classical literature, music and poetry, professional literature and people. This
revised model (table 19.) also acknowledged the importance of context and took the
perspective that concepts do not exist as an “out there reality” but are “formed from
experience” (Chinn and Kramer 1995, p78).
Table 19. Chinn and Kramer’s (1995) model of concept clarification
1. Select concept 2. Clarify purpose 3. Identify sources of evidence
4. Explore contexts and values
5. Formulate criteria
Summarised from Chinn, P.L. and Kramer, M.K. (1995) Theory and Nursing a
systematic approach, Mosby, St Louis, Missouri, p81-89.
In considering the nature of concepts Chinn and Kramer (1995) argue that all
concepts lie along a continuum from the empiric (more directly experienced) to the
abstract (more mentally constructed). Defining a concept as “a complex mental
83
formulation of experience” Chinn and Kramer (1995, p58-60) go on to illustrate how
directly observable concepts (such as gender, height and weight) can be observed or
measured using standardised instruments, but that evaluating any concept becomes
more complex as one moves along the continuum towards the relatively abstract.
Cardio-vascular fitness is given as an example of a “mid range” concept, there being
no object such as cardio-vascular fitness, however it is “indirectly observable” as
several empiric indicators can be used to aid its definition. Understanding highly
abstract concepts (sometimes called constructs) such as wellness or self-esteem is in
Chinn and Kramer’s (1995) view “inferred from multiple direct and indirect
observations”.
2.3.2.4 Walker and Avant
Walker and Avant’s (1988) model of concept analysis describes six stages (table
20.)
Table 20. Walker and Avant’s (1988) model of concept analysis
1. Identification of how the concept is used 2. Determination of defining attributes
3. Construction of a model case, illustrating all defining attributes 4. Development of additional cases describing the concept in different ways
5. Identification of antecedents and consequences 6. Definition of empirical referents
From Walker, L.O. and Avant, K.C. (1988) Strategies for Theory Construction in
Nursing, Norwalk, CT. Appleton & Lange.
That concept analysis has been linked only to the Walker and Avant method
(Weaver 2005) and overuse of this method in nursing research (Rew 2005) have
been highlighted. Rew (2005) considers that this model represents a failure to move
beyond the analysis stage to the developing and testing of theory in nursing research,
while Weaver (2005) points to “the threat to study validity and comprehensiveness
resulting from using simplified critical inquiry processes and obviously invented
cases”. Despite these criticisms and further cautionary arguments offered by
Rodgers this model prompted a number of “conceptual clarifications” relating to
nursing (Paley 1996).
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2.3.2.5 Rodgers
Rodger’s (1993b) evolutionary model, describes eight stages of investigation in
concept analysis (table 21.). The focus of this model is clarification of the current
use of a concept, within the context where it is used. The model acknowledges that
concepts change (evolve) over time, are not static entities (Rodgers 1993b) and
suggests a cyclical pattern to the development of concepts comprising of
significance, use and application (Rodgers 1993b). Significance relates to how
concepts assist in solving practical problems in the empirical world. Use refers to
the attributes of a concept and how concepts are commonly expressed. Application
refers to the scope, strengths and limitations of concepts in specific contexts. These
phases are not sequential and may overlap. The evolutionary approach focuses upon
the use phase of the cycle. Rogers is critical of essentialist approaches to concept
analysis, asserting that concepts are dynamic, “fuzzy” rather than “crystal clear” and
possessing “pragmatic utility” rather than an inherent “truth” (Rodgers 1993, p73).
This notion of “pragmatic utility” has been developed further by Morse.
Rodgers argues that concepts are formed by the identification of characteristics
common to a class of objects or phenomena and the abstraction and clustering of
these characteristics, along with some means of expression (usually a word).
Extending upon this Rodgers argues that when the attributes which comprise a
concept are unclear, the ability to communicate and categorise phenomena are
severely limited and that identification of these attributes (thereby defining the
concept) will allow more effective use of the concept (Rodgers 1993). By
considering the antecedents, attributes and consequences of concepts, as well as
changes over time and within context, Rodgers (2000) argues that the non-linear and
inductive approach of her method offers greater analytic rigour than sequential
methods such as those of Walker and Avant, or Wilson. Further she proposes that
attention to context and changes over time facilitates appreciation of the dynamic
and changing nature of concepts, where other models are bound to philosophical
perspectives which view concepts as static, unchanging entities.
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Table 21. Stages in Rogers’ (1993) model of conceptual analysis
1. Identify the concept of interest and associated expressions.
2. Identify and select an appropriate realm (setting an example) for data collection
3. Collect data regarding the attributes of the concept, along with surrogate terms, references, antecedents and consequences.
4. Identify concepts related to the concept of interest. 5. Analyse data regarding the above characteristics of the concept.
6. Conduct interdisciplinary or temporal comparisons, or both if desired. 7. Identify a model case of the concept, if appropriate.
8. Identify hypotheses and implications for further development.
From Rodgers B. (1993) Concept analysis: an evolutionary view. In Rodgers, B. and Knafl, K.A. (Eds.), Concept Development in Nursing. Saunders, Philadelphia,
p78.
Rogers (1993) is prescriptive about how data is collected for the literature review,
suggesting that a randomly selected sample of 30 articles or 20% of the total
(literature) population are necessary for an adequate review, with a minimum time
span of 3 years. Rodgers (1993) asserts that such a sampling strategy shows rigour
in its selection, displays a strong rationale for all decisions, obtains effective
representation of the literature and diminishes researcher bias. This researcher
questions this overtly inflexible and quantitative selection process, which may lead
to important data being missed and the selection of less significant literature for
review. Regarding literature, Rodgers has also been criticised for not citing her data
sources in published papers (Paley 1996). In reviewing the literature Rogers (1993)
acknowledges that her approach resembles other models of concept analysis in that
the researcher should seek to identify data relevant to the attributes, antecedents,
consequences, surrogate terms and related concepts along with the references of the
concept.
2.3.2.6 Morse
Morse’s model of concept analysis has been used in nursing to develop practice and
curriculum maturity matrices to identify strategies for curriculum and/or practice
development (Latter et al 2000). Morse (2000) advances an approach which goes
beyond the identification of a concept’s linguistic characteristics; her method (table
22.) is one of exploring the “pragmatic utility” of a concept, thereby contributing to
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understanding the function of the concept and its “applicability” to the world (Morse
2000, p 333). While determining this pragmatic utility involves critically appraising
the literature, Morse points to the way in which the focus of this process is the
exploration and development of the concepts and their usefulness to science (Morse
2000). In examining various conceptualisations of the concept (overt or covert) and
ways the concept is being used by other researchers in models and theories,
examining pragmatic utility provides information about implicit and explicit
assumptions and contributes to the evaluation of the logical coherence of the
concept. Exploring pragmatic utility thus differs from other forms of literature
review in that “it is a process of active enquiry, using the literature as data” (Morse
2000, p333).
Table 22. Morse’s principles of assessing pragmatic utility
Summarised from Morse, J.M. (2000) Exploring Pragmatic Utility: Concept Analysis by Critically Appraising the Literature. In Rodgers, B.L. and Knafl, K.A.
(Eds.), Concept Development in Nursing, Saunders, Philadelphia, pp333-352.
1. Be clear about the purpose of the enquiry. Delimit the concept to be explored, identify allied concepts and converse concepts – these are used
to guide the literature search. 2. Ensure validity by searching all relevant sources of information (e.g.
databases) in an attempt to avoid disciplinary bias in the gathering of literature. In reading the literature pay attention to definitions and
attributes of the concept, any assumptions made about it and to the research question of studies.
3. Identify significant analytical questions. Highlight definitions and variables which are indicators of the concept’s attributes or
characteristics. Record assumptions made or inferred from the research question, research focus and content of the paper.
Refine the research question. Consider if consensus about the definition of the concept exists, whether definitions vary or are omitted in the
literature, whether the concept is used in the same way and used consistently by different disciplines and studies. The research question
may arise from the need to clarify the concept, to compare and contrast disciplinary perspectives, to contrast competing concepts, to identify
conceptual gaps or boundaries or to identify conceptual adequacy. 4. Synthesise results. Use of a data matrix with analytical questions and
dimensions forming the criteria for the axes is suggested as a means to organise the results of the concept analysis and to provide an overview of
the concept.
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In presenting these guidelines Morse (2000) emphasises that systematic approaches
to concept analysis do little justice to the depth of inquiry or the cognitive processes
involved. She clearly states that what she has set out form guiding principles, to be
used with thoughtfulness and if necessary added to or deviated from.
2.3.4 Concept analysis - Summary
In tracing the origins of concept analysis and the changes over time manifest in the
different models one can discern the move from Wilson’s focus on “linguistic
philosophy” to acknowledgement of the link between meaning and context, through
recognition that concepts are not static, well defined entities and the associated
questioning of essentialist perspectives, and thence to the further development of the
notion of “pragmatic utility”. Thus an approach no longer bound completely to
linguistic characteristics but more allied to and informed by analytical philosophy
has emerged (see also section 3.3).
2.4 Sampling Strategy
Patton (1990) identifies and describes 16 types of purposeful sampling. These
include: extreme or deviant case sampling; typical case sampling; maximum
variation sampling; snowball or chain sampling; confirming or disconfirming case
sampling; politically important case sampling and convenience sampling.
2.4.1 Purposive, Criterion based Sampling
A strategy where members of a sample are chosen with a purpose in relation to key
criteria (Patton 1990), because they have particular features or characteristics which
facilitate detailed exploration and understanding of the questions and themes of the
research (Ritchie et al 2003). The sample should be likely to generate rich
information on the type of phenomena which need to be studied (Miles and
Huberman 1994, p43) and although selected deliberately, purposive sampling must
remain justifiable and amenable to external scrutiny (Ritchie et al 2003).
2.4.1.1 Snowball Sampling
Also called chain sampling is a strategy for identifying information-rich key
informants (Miles and Huberman 1994, Patton 1990). By asking a number of people
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who else one should speak to the “snowball” becomes increasingly bigger. Those
people who are mentioned repeatedly take on a special importance (Patton 1990).
2.4.2 Sample Size
Patton highlights that there are no rules for sample size in qualitative enquiry and
that the logic of purposeful sampling is quite different from that of probability
sampling, the latter requiring adequate sample size, while the former emphasises
information-richness and the analytical capabilities of the researcher (Patton 1990).
This is further emphasised by Starks and Trinidad (2007) who highlight that as each
interview participant can generate hundreds or thousands of concepts, large samples
are not required to generate rich data sets.
2.5 Interviews
Denzin (1978) and Patton (1990) write about types of qualitative interview
representing a continuum from unstructured to rigidly structured interview styles.
Patton identifies informal, conversational interviews, the general interview guide
approach, standardised, open-ended interviews and closed fixed-response interviews
At the unstructured end of the continuum flexibility is maximised and data gathered
from each respondent may differ (there being no pre-determined questions), while at
the rigidly structured end data may be easily analysed but the respondent’s meaning
may be distorted. A semi-structured approach represents middle ground. In the
general guide approach issues to be explored are decided in advance – allowing the
same areas to be covered with each respondent and providing a means of ensuring
that relevant areas are covered, while allowing flexibility in the wording and
sequence of questions asked. The standardised open-ended interview consists of a
standardised set of open ended questions, posed to each respondent. This limits
flexibility in probing and reduces flexibility and spontaneity but provides systematic
and thorough data.
Conducting semi-structured in-depth interviews requires skills and knowledge,
including an understanding of the aims of the project, the ability to establish a
rapport with the interviewee (Silverman 2006, Patton 1990) an ability to use probing
techniques (Silverman 2006, Patton 1990) and the ability to maintain control of the
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interview (Patton 1990). The interview guide or “schedule” (a list of questions or
general topics that the interviewer wants to explore) is prepared to insure that
basically the same information is obtained from each person; however there are no
predetermined responses and the interviewer is free to probe and explore within
these predetermined inquiry areas. Interview guides ensure good use of limited
interview time; they make interviewing multiple subjects more systematic and
comprehensive and they help to keep interactions focused.
Tuckman (1972) points to the way in which collecting interview data provides us
with a chance to access what is 'inside a person's head', rendering accessible what a
person knows (knowledge and information), what a person likes or dislikes (values
and preferences), and what a person thinks (attitudes and beliefs). This though may
represent a limiting factor, respondents will provide their perspectives and
perceptions including personal bias or simple lack of awareness (Patton 1990),
though such bias or lack of awareness may represent important data in and of
themselves.
2.5.1 Focus Group Interview
Focus groups are considered appropriate in securing rich experiential information,
insights and interpretations from participants (Carey 1994, Janesick 1994, Fontana
and Frey 1994, Polgar and Thomas 2001). Focus group interviews capitalise on
group interactions (Morgan1997), members of the group being interactive, dynamic
suppliers of information (Schratz 1993, Carey 1994). Though there are no rules for
sample size in qualitative enquiry (Patton 1990), recommended optimal focus group
size varies from 5 to 12 (Carey 1994). The main problem associated with small
group size is not that validity is compromised, the logic of purposeful sampling
being quite different from that of probability sampling (Patton 1990), but the
difficulty of sustaining the discussion if the group numbers less than six (Morgan
1997). Conducting focus group interviews requires facilitation skills of the
researcher, coupled with the ability to stand back from the discussion and allow the
group dynamics to emerge (Silverman 2006). The presence of a research assistant
who observes the interview and makes field notes enables the researcher to
concentrate on the often fast-paced flow of information as it is generated (Carey
1994).
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2.5.2 Key Actor Interview
Key informants are people who are particularly knowledgeable and articulate
(Patton 1990), termed key actors by Fetterman (1998) to avoid any stigma associated
with the word informant. Such individuals can provide:
“… detailed historical data, knowledge about contemporary interpersonal
relationships (including conflicts), and a wealth of information about the
nuances of everyday life” (Fetterman 1998, p48).
2.5.3 Negative aspects of interview methodology
Interviews capture the perspectives of the interviewee(s) on the subjects discussed
and as such should not be regarded as representations of absolute truth (Yin 1994).
Bias (Patton 2005, Yin 1994), poor recall and flawed articulation (Yin 1994) may
render accounts less than accurate. Respondents’ desire to please the interviewer or
to adopt the interviewer’s theoretical perspectives may also cause distortion within
the data (Yin 1994). In a focus group situation the presence of other respondents
makes anonymity impossible; the interview is therefore less confidential.
Additionally, while group interaction may be a positive effect associated with focus
group interview methodology (Morgan 1997, Carey 1994, Schratz 1993), the
presence of other participants may exert a censoring or conforming influence (Carey
1994), producing less candid responses. Triangulation strategies have been utilised
to address some of the methodological difficulties, which are inherent to interviews
(see section 2.7).
2.6 Coding
In initially describing their constant comparative method (discussed in section
2.6.2.1) Glaser and Strauss (2006) considered that while coding may be done more
elaborately it need only be a process of noting categories in margins. Strauss and
Corbin emphasise the dynamic, fluid nature of coding, but like Strauss (1987) point
to three types; open, axial and selective.
2.6.1.1 Open Coding
A process of “opening up the text to reveal the thoughts, ideas and meanings it
contains” (Strauss and Corbin 1998, p102) refers to the initial detailed examination
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of the data (Strauss 1987). Called line-by-line coding by Charmaz (1990, 1994),
each line of the interview script is examined to define the actions, events and
subjects’ meanings within them. The conceptual name or label should be suggested
by the context in which the event is located (Strauss and Corbin 1998), where names
or labels assigned in coding are the words of respondents, they are often referred to
as “in-vivo codes” (Glaser and Strauss 2006). While line-by-line analysis is
acknowledged to be very time consuming it is also considered to be the most
generative (Strauss and Corbin 1998).
2.6.1.2 Axial or Focussed Coding
Strauss (1987) and Strauss and Corbin (1998) describe a second phase of axial
coding which is more focussed upon an emerging category and begins the process of
re-assembling data that were fractured during open coding (Strauss and Corbin
1998). The term axial refers to the way in which coding happens around the axis of
a category, linking categories at the level of properties and dimensions (Strauss and
Corbin 1998). For Strauss (1987) and Glaser and Strauss (2006) the process of
constant comparison (discussed in section 2.6.2) is the route through which initial
concepts (the product of open coding) are converged into categories. This second
phase of coding, which Charmaz calls focused (or selective) coding uses the
products of the line-by-line coding that reappear frequently to sort large amounts of
data. In focused coding activity is more directed and, typically, more conceptual
than the initial (line- by- line) coding. Categories represent important analytical
ideas which emerge from the data (Strauss and Corbin 1998). From the focused
codes in her studies, Charmaz develops the categories for synthesizing and
explaining the data, which in turn shape her construction of analytic frameworks.
Charmaz’ memo writing is “the intermediate step between coding and the first draft
of the complete analysis.” (Charmaz 2003, p261).
2.6.2 Data Analysis
The philosophical basis of the data analysis is interpretevist in nature, seeking to
capture the meanings intended by respondents and to minimise effects of
researcher’s a-priori knowledge.
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2.6.2.1 Constant comparative method
Glaser and Strauss (2006) point to comparative analysis as a widely used and
general analytical method for generating theory, applicable for social units of any
size (Glaser and Strauss 2006). In developing the constant comparative method
Glaser and Strauss sought to aid the analyst in generating theory which is integrated,
consistent, plausible and close to the data (Glaser and Strauss 2006). By a process
of constant comparison the researcher is forced to consider much diversity in the
data as emerging categories synthesised at many levels, are continually developed
and checked for relevance (Glaser and Strauss 2006). Each time a researcher codes
an incident, a process of comparing this with each incident coded in the same
category is undertaken. Thus bird, kite and aeroplane may be coded for their
common characteristic of “flight” (Strauss and Corbin 1998). The constant
comparison of incidents aids the researcher in considering the full range of types of
the category, conditions which accentuate or minimise it, its major consequences,
how it is related to other categories and its other properties (Glaser and Strauss
2006). When, inevitably after coding for a category three or four times, the
researcher encounters conflicts in which aspects should be emphasised Glaser and
Strauss (2006) advocate that coding is halted and a memo of the researchers’ ideas
recorded; this process is designed to record the researcher’s thoughts while they are
fresh and allow time for reflection to carry the thought process (grounded in the
data, rather than speculative) to its logical conclusion.
Focussing on categories which emerge from the data ensures that the categories are
relevant and rich, fitting the data rather than forcing it (Glaser and Strauss 2006).
This process is dependent upon the skills and sensitivities of the researcher (Glaser
and Strauss 2006); requiring the researcher to initially ignore the literature of theory
in the area under research to ensure that emerging categories are not contaminated
by extant concepts from different areas. Only once the analytic core of categories
has emerged should similarities and convergences with the literature be considered
(Glaser and Strauss 2006).
As coding continues, the units of constant comparison change, initially incident is
compared with incident; gradually incident is compared with properties of
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categories. In this way the theory develops as different categories and their
properties become integrated through constant comparisons that force the analyst to
make some related theoretical sense of each comparison (Glaser and Strauss 2006).
Discussions contained within the memos provide the content behind the categories
and categories in turn become the major themes of the theory. In composing the
theory memos on each category are collated and the data is used to provide
illustrations of the theory or to highlight gaps within the theory (Glaser and Strauss
2006). This inductive method of theory development requires the researcher to
make sense of so much diversity within the data that generation of ideas on a higher
level of generality which are conceptually more abstract than the ideas contained
within the raw data is a necessity (Glaser and Strauss 2006).
2.6.2.2 Verstehen
The Weberian concept of verstehen is a method of “interpretative understanding”
(Charmaz 2003) used “to grasp or comprehend the meaning intended or expressed
by another” (Elwell 1996). This process of interpreting or understanding (of
achieving verstehen) relies to some degree on the researcher having a common
frame of reference to the respondent (Parkin 1982). In attempting to “comprehend
social action through a kind of empathic liaison with the actor” (Parkin 1982, p19)
the researcher endeavours to understand the subjective meaning and intent of the
actor – “getting inside their head to understand what he or she is up to in terms of
motives, beliefs, desires, thoughts” (Schwandt 2000, p192). Weber differentiates
between two types of verstehen, direct observational understanding “aktuelles
verstehen” and explanatory understanding “erklarendes verstehen” (Parkin 1982,
p20). Direct observational understanding is relatively simple and obvious to
comprehend form observation, while explanatory understanding is required to grasp
motives and subjective meanings, though Parkin (1982) argues that the first kind of
verstehen is simple observation with no real understanding attached to it.
Verstehen is considered to be rooted in interpretivism and hermeneutics (Schwandt
2000). The interpretevist view of verstehen has been linked to Husserl’s
“intentional object” – that is the object as meant, as intended by the respondent in
the acts of thinking, remembering, willing and imagining (Natanson 1963, p283).
This contrasts with the Heidigger inspired (Schwandt 1998) perspective of
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philosophical hermeneutics where understanding is participative and meaning is
negotiated mutually in the act of interpretation, the researcher being unable to
remain an uninvolved observer and instead being active in the construction of
meaning (Schwandt 2000).
2.6.3 Reduction
Mastering the data forces the analyst to engage in reduction of terminology (Glaser
and Strauss 2006). This is achieved through a process of discovering underlying
uniformities in concepts (Strauss and Corbin 1998), categories or their properties,
facilitating the formulation of theory with a smaller set of higher level concepts
(Glaser and Strauss 2006).
2.6.3.1 Data Matrix
While Glaser and Strauss (2006) and Charmaz (2003) make extensive use of memo
writing during analysis, Strauss and Corbin (1998) emphasise the early construction
of mini-frameworks to record relationships amongst concepts during axial coding.
2.7 Triangulation
In a review of literature on triangulation and multi-method strategies published since
1960 and research books specifically focusing on triangulation, Thurmond (2001)
found triangulation to be the combination of at least two or more theoretical
perspectives, methodological approaches, data sources, investigators, or data
analysis methods. The term is derived from the field of land surveying (Patton
2005). The intent of using triangulation is to decrease, negate, or counterbalance the
deficiency of a single strategy, thereby increasing the ability to interpret the findings
(Denzin and Lincoln 2005, Patton 2005, Thurmond 2001). Data triangulation is the
use of more than one source of data, methodological triangulation the use of more
than one method, investigator triangulation the use of two or more researchers with
different backgrounds and theoretical triangulation the use of more than one theory
during the analysis of the same data set; within a single investigation (Streubert and
Carpenter 2006). In facilitating the researcher’s evaluation of consistency and
inconsistencies elicited, triangulation can provide deeper insight into the relationship
between the enquiry approach and the phenomenon studied (Patton 2005), though
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triangulation strategies may not be able to address all themes elicited from interview
analysis. Areas where documentary analysis as a triangulation strategy has been
particularly useful are discussed in sections 2.8.4 and 3.14.
2.8 Documentary Analysis
Documents represent a rich body of descriptive data (Hodson1999) forming a
valuable socio-historical record, which may cover long periods of time (Yin 1994,
Weber 1990), many events and settings (Yin 1994). Love (2003) points to the
proliferation of documents which surround us, their pervasive role in everyday life
and how they can provide an important avenue of voice, interpretation and meaning
within research. Grounded in the context they represent (Krippendorff 2004, Love
2003, Weber 1990), documents provide the researcher with information about things
which cannot be otherwise observed (Patton 2005), indeed not undertaking
documentary analysis may leave a gap in the ability to understand the issue or
question at hand (Love 2003). Content analysis is considered to be a systematic,
reproducible method of analysing text, allowing corroboration of findings from other
forms of data collection (Krippendorff 2004, Yin 1994), and is frequently used to
enrich other qualitative methods (Love 2003, Hodson 1999).
Historically content analysis procedures have been used to create quantitative
indicators which assess the degree of attention or concern devoted to cultural units
such as themes, categories or issues (Weber 1990). Initially quantitative evaluation
used simple word counting or measurement of column inches in the analysis of
newspapers (Krippendorff 2004) such as Tenney’s 1912 Scientific Analysis of the
Press (Tenney 2009). From 1910, Max Weber used such an approach to newspaper
analysis (especially the advertising sections), embedding the process in qualitative,
critical and comparative research questions (Krippendorff and Bock 2009). Over
time content analysis has changed from an overtly quantitative undertaking, based
upon the naive belief that documentary content is an objectively describable entity
(Krippendorff and Bock 2009) to one where inferences which can be made from
texts to the context of their use is central (Allport 2009, George, 2009, Krippendorff
and Bock 2009, Weber, R.P 1990). This said, not all early content analyses relied
upon word counting or column-inches as a measure, Matthews’ 1910 content
analysis Study of a New York Daily (Matthews 2009) utilised categories, however
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this analysis has been criticised for failing to provide information on how and why
categories were chosen and for its lack of inference (Krippendorff and Bock 2009).
So, while early content analysis rested on the notion that content was an objectively
describable entity, making specific inferences from texts to their contexts is now
considered to be the defining feature of content analysis (Krippendorff and Bock
2009). Inferences which can be made from documentary sources are about the
sender of the message and the audience of the message as well as the message itself
(Weber, R.P. 1990), Krippendorff (2004) also emphasises inference from how the
audience of the message receives its content, the social situations into which the
messages enter and the effects of the message on them.
McCulloch (2004) discusses three broad approaches in the contemporary analysis of
documents: positivist, interpretevist and critical. The positivist approach
emphasising objective, systematic and quantitative evaluation; the interpretevist
emphasising the socially constructed nature of documents; and the critical being
theoretical and overtly political in nature (McCulloch 2004). Five types of symbolic
units useful in content analysis: physical, syntactical, referential, prepositional and
thematic are identified (Krippendorff 2004). Syntactical units may be words,
sentences, paragraphs or whole texts. Referential units are instances where a
physical or temporal unit is referred to in the text; this may be an individual, event or
issue. Referential units can be used to measure the meaning attached to such an
event, individual or issue. Prepositional units focus on the constituent parts of
communication. Thematic units relate to how concepts of interest in the text which
can be used to develop interpretations and explanations of the content, can be
identified structurally (Krippendorff 2004, p103). While Holsti (1969, p116)
considered a theme to be “a single assertion about some subject”, Krippendorffs’
(2004, p109) framing of a theme is less rigid, recognising that “…thematic units may
have to rely on textual features that are distributed throughout a text…”
2.8.1 Content analysis – qualitative or quantitative?
That social phenomena are both generated by and represented within texts and
images is highlighted by Krippendorff (2004), who considers that reading
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documents is a qualitative undertaking – whether or not this is subsequently
converted into quantitative information and regardless of the quantitative or
qualitative labels attached to content analysis activity. Weber (1990) asserts that
“…the best content-analytic studies use both qualitative and quantitative operations
on texts.” Perhaps the clearest discussion of the debate regarding the relative merits
and uses of quantitative and qualitative approaches to content analysis is provided
by George (2009), who frames this in terms of frequency and non-frequency content
indicators. “We employ the term ‘non-frequency’ to describe the type of non-
quantitative, non-statistical content analysis, which uses the presence or absence of
a certain content characteristic or syndrome as a content indicator in an inferential
hypothesis. In contrast a ‘frequency’ content indicator is one in which the number
of times one or more content characteristics occur is regarded as relevant for
purposes of inference.” (George, 2009, p144-145).
Thus whether qualitative or quantitative approaches are used, inference remains
central to content analysis. Justification for inferences within the context of their
use employs the notion of “analytical constructs”, by which the researcher makes
explicit the analytical framework they have used in making inferences (Krippendorff
and Bock 2009, Krippendorff 2004).
2.8.2 Problems with Content Analysis
Issues of reliability including truth, bias and the representativeness of documents are
discussed by Tosh (2002), who suggests that evaluating the ability of the author to
render a faithful account of what is being reported should be the analyst’s starting
point. Temporal as well as authorial factors are highlighted as sources of potential
bias (Hodson 1999). Thus information about documentary accounts such as the
identity, role, affiliations and likely perspectives of the author as well as the year of
observation should be recorded during data collection, acknowledged and
considered during analysis (Hodson 1999). Use of more than one documentary
source has also been suggested as a means to reduce the effects of author bias (Tosh
2002).
To make valid inferences from text it is important that the classification procedure is
reliable – in the sense of being consistent, with different people coding the same text
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in the same way (Weber 1990). Krippendorff (2004) points to several types of logic
capable of relating data to their contexts and the need for researchers to render any
assumptions, the logic they have used and analytical frameworks they employ
explicit.
2.8.3 Content Analysis - Ontology
The utility of content analysis is strongest in addressing linguistically constructed
social realities (Krippendorff 2004) – that is where language in the texts being
analysed is rooted in the situation or phenomena it describes. Content analysis also
presupposes familiarity with the language of analysed texts; awareness of the
vocabulary and its subtle discursive conventions increasing the likelihood of
successful analysis (Krippendorff 2004).
2.8.4 Content Analysis – Epistemology
Triangulation strategies are discussed in section 2.7, but the author would summarise
her epistemological approach to triangulation as a bid to corroborate data and form
as comprehensive an account as possible, by capturing different perspectives using
different methods and data sources. This led to a problem-driven content analysis
(Krippendorff 2004), underpinned by the belief that systematic reading of specific
texts can provide corroborating accounts or highlight variations.
Within the context of this research the researcher believes content analysis of job
advertisements in historical journals to be a valuable triangulation strategy,
particularly in addressing:
When titles and terminology associated with specialisation entered the
professional language of podiatry
When differentiation and areas of specialised practice became part of
podiatry’s way of working
Timelines for the emergence of specialised practice as a reflection of
changing social forces
Grading and banding structures linked to different specialties as a reflection
of status and remuneration
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The degree to which professional credentials have been linked to specialised
practice
Documentary analysis is based on the assumption that the real world is being
reported and recorded (Hodson 1999). Within this research, the assumption has
been that historical job advertisements reflected the contemporary requirements of
the employer and status of the prospective employee. The author recognises that
advertisements may have varied in their accuracy, specificity and detail; issues of
space and cost involved in entries in a paper journal may have had an impact, as may
have the advertisers’ experience in composing advertisements and a possible lack of
clarity about what was required.
2.8.5 Content Analysis – Limitations
The author recognises that some job advertisements will not have been included in
the historical journals which were searched. Other forms of advertising for example
bulletin boards, alternative publications such as newspapers, local magazines and
internet advertising may have been utilised. Some posts may never have been
formally advertised – being communicated by word of mouth or filled by a
previously known individual. Conversely duplication of advertising was also
evident. Where the position advertised was clearly the same post included in
subsequent advertisements, the duplicates were excluded (though interestingly some
posts seemed to be particularly difficult to fill, being advertised for many
consecutive months). These inclusions and exclusions are likely to be imperfect,
reflecting Hodder’s (1998) point that historical documents cannot be checked for the
author’s original meanings and intent.
Within the context of this research, inter-coder variation was not an issue, there
being only one researcher. However Krippendorff (2004) highlights reliability
issues involving inconsistencies in coding which may arise from ambiguous coding
rules, ambiguities within the text, cognitive changes within the coder or simple
errors. Weber (1990) acknowledges that concept analysis is difficult and time
consuming to do well, pointing to use of computers in order to reduce the drudgery
involved. Given the nature of the documents used in this instance, computer-aided
analysis was not possible. While the method used has been clearly stated and
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adhered to, the researcher acknowledges the possibility of human error associated
with a hand-search of many editions of historical journals.
2.9 Research Governance
In 2005 the Department of Health set out the second edition of its framework for the
governance of research in health and social care. Research governance is intended
to improve research quality and safeguard the public by enhancing ethical and
scientific quality, promote good practice, reduce adverse incidents, ensure lessons
are learned and prevent poor performance and misconduct (Department of Health
2005a). The framework is applicable to all research which relates to the
responsibilities of the Secretary of State for Health and its terms include clinical and
non-clinical research, including that undertaken by universities, within the health
and social care systems (Department of Health 2005a).
2.9.1 Confidentiality and Anonymity
The Concise Oxford Dictionary (2008) defines confidentiality as: “intended to be
kept secret or entrusted with private information” while anonymity is defined as:
“not identified by name; of unknown identity”. Anonymity and confidentiality are
closely connected (Wiles et al 2007), yet still distinct concepts (Wiles et al 2006);
participant anonymity often being the mechanism through which confidentiality is
maintained (Giordano et al 2007). While Giordano et al (2007) and Grinyer (2002)
have called into question assumptions that anonymity is desired by all research
participants, it is still considered to be a requirement in the ethical conduct of
research (Walford 2005, Ryen 2004, British Sociological Association 2002).
However the extent to which anonymisation is successful varies according to the
research context (Wiles et al 2007, Walford 2005). Data derived from interviews
with high-profile participants renders the possibility of identification more likely, as
readers may be familiar with respondents’ perspectives and expressions. Thus
confidentiality cannot be guaranteed. Researchers need to be transparent about this
fact, communicating to participants that they will as far as humanly possible protect
participants’ identities (Wiles et al 2007, Walford 2005).
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2.9.2 Data Protection
Legal requirements under the Data Protection Act (Department of Health1998)
explicitly state that:
“…data legitimately processed for research or statistical purposes, as long
as such processing neither causes substantial harm or distress to the data subject nor is used to support measures or decisions in relation to
individuals, are exempt from certain provisions of the Act. Such data can be kept indefinitely and are exempt from the subject access rights if the results
of the work are not made available in a form from which data subjects can be identified. Use of such data for research, although obtained for other
purposes will not breach the second principle (use incompatible with the purposes for which it was obtained) and hence will not be unlawful on those
grounds. However, this does not absolve the data controller from the obligation, in order to comply with the first principle, to give the data subject
general information about intended uses”.
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3.0 METHODS
3.1 Ontological and Epistemological Underpinnings
The researcher’s work has developed over time, beginning with an initial interest in
how specialist podiatrists worked which subsequently evolved to encompass
specialisation as a concept; then focussing on podiatrists specialising in diabetes as
an exemplar. The ontological stance of this research has been a mix of pragmatic
and inductive (Patton 2005). Development and clarification of the research questions
flowed from the concept analysis which was used to evaluate the maturity of the
concepts of specialisation and diabetes specialist podiatry. One main research
question and four related sub-questions were identified. Thus having considered
what can be known about the research area (the ontological question) – research
methods suited to answering the questions were selected. An inductive
methodology was utilised in analysing the interview data, reflecting the researcher’s
belief that the answers to the research questions lay within the knowledge and
experiences of specific individuals. As a podiatrist, the researcher did not come to
this research in a naive, “tabula-rasa” form. Therefore, the researcher has utilised
verstehen and constant comparison to minimise the effects of her a-priori knowledge
– acknowledging her status as a podiatrist with an interest in specialisation. Thus
the epistemological stance is interpretevist, allied to Husserl’s “intentional object”
rather than the Heideggerian (Schwandt 1998) perspective of philosophical
hermeneutics (see also section 3.12.1 Verstehen).
The following sections, arranged chronologically, document the progress and
evolution of the research, its aims, adherence to research governance, present the
rationale for methodological decisions and describe the data collection, handling and
analysis techniques.
3.1.1 Initial Research Interest
The researcher’s initial interest in this area stemmed from her observation of
specialist podiatrists working in mixed-profession settings. Variations in the roles of
the podiatrists and the ways in which they worked were significant. Discussions
with podiatry managers, diabetes, rheumatology and musculo-skeletal specialist
podiatrists elicited that within the profession of podiatry, specialisation in diabetes
podiatry is viewed as having established a precedent for specialisation and that
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diabetes podiatry has been used as a driver, justification and template for developing
other specialist podiatry services.
3.2 Literature Review
The literature review began by reading widely in the areas of professional sociology
and the philosophy of caring professions, in order to site the study appropriately and
ground it in the wider professional literature. This enabled clarification and
refinement of the research focus and identification of the research aims.
3.2.1 Research Aims
To explore the role (or what Zetka [2003] would call the “task bundle”) of
the diabetes podiatrist in order to generate a baseline understanding in a
hitherto unresearched area.
To trace the origins, change over time and current status of diabetes podiatry.
3.3 Concept Analysis
Following the preliminary literature review, concept analysis specifically employing
a “Morse” model was selected as a useful way to gain an understanding of
specialisation and to evaluate the maturity of diabetes specialist podiatry as a
concept. The rationale for using this model was based on its evaluation of
“pragmatic utility” as a means of understanding the function of the concept and its
applicability to the world. Additionally, the less procedural nature of the Morse
model of concept analysis prioritises cognitive processes over rigid, systematic
evaluation, allowing the concept analysis to be tailored to the area of interest and
permitting greater depth of enquiry. The Morse approach was complamented and
extended by the consideration of concepts related to the concept of interest (after
Rodgers 1993), namely “diabetology” and “diabetes specialist nursing” to capture
the preconditions, characteristics and consequences of other healthcare professions
specialisation in diabetes practice.
The ability of concept analysis to encompass the linguistic issues surrounding what
this author initially called “diabetes specialist podiatry” (because this is the most
commonly used term in the literature) represented a further compelling reason for
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choosing this methodology; although the language involved is only one facet
amongst many.
The concept analysis highlighted the immaturity of and need to clarify the concept
“diabetes specialist podiatry”, leading to the main research question:
What does specialisation in diabetes podiatry mean?
and to related sub-questions:
How did diabetes evolve as a podiatric specialty?
What is the impact of specialist titles?
What does specialisation in diabetes podiatry mean for services and the
profession of podiatry?
Is specialisation in diabetes podiatry sustainable?
3.4 Choice of Data Collection Methods
While some documentary data exists in the form of historical texts, Society of
Chiropodists and Podiatrists archives, job advertisements, job descriptions, pay
scales, course content in diabetes specialist podiatry education and editorials in
professional journals; the answers to the research questions lie within the knowledge
and experiences of key actors, managers and individual podiatrists who have held
such posts. For these reasons a qualitative methodology, inductive in nature
featuring focus group and key actor interviews was selected as appropriate in
answering the research questions. This was supplemented by documentary analysis,
forming a data triangulation strategy in a bid to corroborate information, minimising
the effects of respondent bias and the researcher’s a-priori knowledge.
3.5 Recruitment
Initially a purposive, criterion based sampling strategy (Patton 1990, Silverman
2003) led to recruitment from key members of Foot in Diabetes UK and members of
the Society of Chiropodists and Podiatrists Faculty of Management (Faculty of
Management). For the purposes of this study a key member of Foot in Diabetes UK
was defined as a member of the Foot in Diabetes UK executive committee (such
individuals having direct input into the actions and policy decisions of the group) or
a Foot in Diabetes UK member identified as “key” by one of the Foot in Diabetes
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UK executive committee. Inclusion criteria for Faculty of Management members
were that participants should be members of the Society of Chiropodists and
Podiatrists Faculty of Management with current experience of employing diabetes
podiatrists, while those with no such experience were excluded.
3.5.1 Rationale for Sampling Strategy
Selection of these two groups was based upon a-priori knowledge, specifically:
Members of the Foot in Diabetes UK executive committee are also senior and key
individuals within diabetes podiatry and thus represent a rich source of experiential
information. The Foot in Diabetes UK participants included a senior lecturer, a
consultant podiatric surgeon, a consultant podiatrist, and a diabetes specialist and
research podiatrist. In this way diverse areas of practice in diabetes podiatry also
informed these respondents’ perspectives.
In the absence of any formalised educational preparation for specialisation in
diabetes podiatry or agreed career pathway, Faculty of Management members
employing diabetes podiatrists represent the current de-facto controllers of diabetes
podiatry; via their control over advertising, recruitment, the selection and
appointment of podiatrists and the allocation of podiatry time to diabetes services.
Utilising a snowball sampling strategy these informed respondents were asked to
identify other individuals and groups who had insight and knowledge in the area
being researched (see on-going recruitment).
3.6 Interview Schedules
Semi structured interview schedules informed by themes elicited from the literature
and concept analysis were prepared to guide the interviews. Issues concerning
specialisation and specialisation specifically in diabetes podiatry were explored.
Continuing the sequential development of this on-going research and informed by
the constant comparative approach, data from each interview were used to further
refine and inform subsequent interview schedules. Copies of interview schedules
can be found at appendix 3.
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3.7 Research Governance
While this research was not required to meet the standards set out in the Framework
for Governance of Research in Health and Social Care (Department of Health
2005a) the framework’s guiding principles have been followed.
3.7.1 Ethical Approval
Ethical approval was gained from the internal ethics committee of the University of
Southampton. (Ref. No. PO6/11-01) and the study was sponsored and underwritten
by the University of Southampton. The only amendment required by the ethics
committee was that snowball sampling be conducted face-to-face, rather than by
inclusion in the response pro-forma attached to the research information sheet.
3.7.2 Informed Consent, Confidentiality and Anonymity
Via the use of information sheets, potential participants were informed in writing
about the nature of the study and the intended uses for data gathered (meeting one of
the key terms of the Data Protection Act 1998). Provision was made for potential
participants to ask questions pertaining to the research (by including the researcher’s
and main supervisor’s contact details) and the complaints procedure was clearly
stated, thus providing an avenue of recourse for anyone having issues concerning the
research. This information was reinforced verbally before each interview when
participants had a further opportunity to ask questions of the researcher.
All participants gave their written consent to the audio-taping of the interviews. In
adherence to the requirements of the Data Protection Act (1998) all data were
anonymised, such that they no longer constitute personal data and are therefore
exempt from the terms of the act. Within the interview transcripts and text of the
thesis numerical identifiers and pseudonyms have been utilised. The researcher and
participants were aware that a small sample of high-profile respondents increases the
risk of participants being identified, thus in a bid to protect their identities, details
which may make identification of participants more likely (such as locations of
interviews) have also been deliberately omitted. Although the Data Protection Act
(1998) states that research data are “exempt from the subject access rights if the
results of the work are not made available in a form from which data subjects can be
identified” copies of transcripts were made available to participants who requested
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them. Consent forms for focus group interviews included an undertaking to “keep
participants’ identities and content of the discussion confidential” in a bid to
maintain anonymity and thus confidentiality for all respondents. Copies of the
information sheets and consent forms can be found at appendices 4 and 5.
3.8 Piloting
Interview schedules were piloted with participants not subsequently included in the
study, the data transcribed verbatim and analysed thematically, employing a constant
comparative method. The piloting process elicited one question in the Faculty of
Management interview schedule which was poorly worded and therefore
misunderstood by respondents [“How and by whom are the needs of other service
users not encompassed in the diabetes specialist podiatrists remit met?” Wording
was changed to “How does your service meet the podiatry needs of clients not seen
by the diabetes specialist podiatrist?”]. This re-phrasing was intended to aid clarity.
A “mini-pilot” of the amended question with fellow PhD students elicited that it was
now readily understandable (even by non-podiatrists). The Foot in Diabetes UK
members’ pilot interview extended to over two hours. While participants in the pilot
were enthusiastic and happy to discuss issues for this length of time, the researcher
recognised that some respondents may be unable to set aside this amount of time,
this being the case following introductory questions, key issues were located in the
central part of the schedule. In the event, all of the research respondents became
engrossed in the interviews and were happy to speak with the researcher for
protracted periods.
In piloting both schedules some prompts led respondents to cover one or more issues
which were the subject of subsequent questions, this represented valuable experience
for the researcher in facilitating discussion and guiding interviews. Field notes and
reflection following pilots coupled with feedback from the research assistant present
for one pilot focus group also assisted the researcher to improve her technique.
3.9 Change of Methodology in Response to Practicalities
Difficulties encountered in trying to organise a focus group interview with Foot in
Diabetes UK members illustrates how infrequently members meet, one major form
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of communication appears to be an online forum. Though being dispersed across the
UK and meeting infrequently, the existence of an executive committee and their
development of “The National Minimum Skills Framework for Commissioning of
Foot Care Services for People with Diabetes” in conjunction with Diabetes UK, the
Association of British Clinical Diabetologists (ABCD) and the Society of
Chiropodists and Podiatrists - would indicate that there is both formal structure and
political will within the group and that they are capable of inter-agency cooperation.
As a focus group with Foot in Diabetes UK key members was not possible, a series
of key actor interviews were used. The negative aspect of this was that the benefits
of focus group activity (discussed in methodology 2.5.1) were lost, however the
researcher recognises that respondents may have felt able to express themselves
more candidly given the absence of colleagues and the enhanced anonymity afforded
by the key actor interview. On reflection, affording these specific Foot in Diabetes
UK participants the status of key actors within this research process appears to be
more appropriate to their level of involvement in diabetes podiatry and thus their
ability to provide information in addressing the research aims and questions.
3.10 Data Gathering
Initially one focus group (Faculty of Management) and five key actor interviews (4
Foot in Diabetes UK, 1 Skills for Health) were conducted. Times and venues of
interviews were arranged so as to minimise inconvenience for the participants,
involving the researcher travelling to various parts of the country.
The Faculty of Management focus group, arranged to coincide with a scheduled
meeting of “Heads of Service”, included 8 participants. One participant arrived late
to the meeting and despite information about the study, signing the consent
paperwork and the attempts of the researcher to include them, elected to contribute
minimally. Clearly this was their prerogative which had been made explicit within
the focus group information provided to all participants. The researcher respected
this individual’s right to choose their level of response to the interview process.
Key actors were approached individually to arrange appointments for interview.
The venues of these interviews are deliberately withheld so as to protect
participant’s anonymity.
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3.10.1 On-going Recruitment
In order to explore and build upon baseline data generated via the initial focus group
and key actor interviews further informants were identified via a snowball sampling
strategy. In compliance with the terms of the ethical approval for this study the
snowball sampling activity was conducted face-to-face, each research participant
being asked for suggestions for further participants. These suggestions included:
Key actors such as specific physicians, surgeons and podiatrists who were
mentioned by name.
Representatives from management, education, practice (including podiatry,
medicine and nursing), governmental (Department of Health and Skills for
Health) and professional bodies (Society of Chiropodists and Podiatrists,
Nursing and Midwifery Council and Foot in Diabetes UK) – referred to in
broader terms, rather than named individuals.
A group of expert patients
A special interest group for diabetes podiatrists who are all senior diabetes
leads the “Expert Reference Group” was mentioned specifically.
People working in the arena of diabetes in other countries
Guided by the snowball sampling strategy, further interviews were conducted.
These included one focus group interview with the “Expert Reference Group” (10
participants) and a key actor interview with a senior and long-serving Society of
Chiropodists and Podiatrists council member (who was thus well placed to provide
historical and contemporary perspectives from the largest podiatric professional
body). Named individuals who were mentioned by many of the respondents were
senior diabetologists working closely with podiatrists and one high profile podiatrist
specifically named as a key informant by all but one respondent. The researcher was
able to secure key actor interviews with three of the six named diabetologists and
with the high profile podiatrist (Fig. 2.).
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Fig.2. Interviews
3.11 Data Handling
All interviews were transcribed verbatim; including pauses, gestures and laughter as
such paralanguage can convey or change meaning (Vicars 2001). Transcripts were
rendered anonymous in order to protect the identity of respondents and thus enhance
confidentiality. Because all participants within this research are conversant with the
areas under enquiry and possess considerable experiential knowledge, data from the
two types of interview (focus group and key actor) were judged to have been
generated by informed participants and were handled in the same way.
Data were processed by initial line-by-line examination of the transcripts and
coding in order to ensure rigorous examination of the data (in an approach informed
by Charmaz’ [1990, 1994] line-by-line coding). Overt and latent concepts were
identified during this finely detailed first phase coding. The second phase of coding
(which Charmaz calls focussed or selective coding) involved drawing together these
initial concepts, producing focussed codes. These in turn were used to develop
categories, from which an analytical framework was produced. The use of coding
techniques informed by grounded theory was felt by the researcher to offer a
thorough approach, linked to verstehen within a qualitative paradigm. This detailed
and rigorous coding process is tabulated and clearly accessible to scrutiny; it is
readily auditable and meets requirements of transparency detailed in Yin’s chain of
Snowball Sampling Strategy
Faculty of Management – focus group interview (8 participants) Skills for Health respondent – key actor interview Foot in Diabetes UK executive committee members – 4 key actor interviews
Expert Reference Group – focus group interview (10 participants) Society of Chiropodists and Podiatrists committee member – key actor interview
Named high-profile podiatrist – key actor interview Senior diabetologist working with podiatrists – 3 key actor interviews
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evidence approach (Yin 2003). An example of the researcher’s work in this area is
appended to this document (Appendix 6).
3.12 Data Analysis, Rationale
Analysis of interview data was thematic, utilising the constant comparative method.
This involves the inspection and analysis of all parts of the data (Silverman 2003).
By forcing the analyst to consider much diversity in the data the constant
comparative method aids the generation of theory which is integrated, consistent,
plausible and close to the data (Glaser and Strauss 2006). This inductive approach
offers a methodological “good fit” in addressing the research questions and its use
reflects the researchers’ epistemological stance in her belief that answers to the
research questions lay within the knowledge and experiences of key individuals.
The researcher acknowledges her a-priori knowledge (Glaser and Strauss 2006) of
both the clinical area and the professional-sociological theories which are related to
it - clearly meaning that she was unable to come to the research “tabula rasa”.
During data analysis the researcher sought to minimise the effects of her a priori
knowledge by strict adherence to the constant comparative method, which forces the
researcher to focus upon the data - and to the use of verstehen.
3.12.1 Verstehen
Within the findings section, data is presented thematically, highlighting those issues
which were of particular importance from the perspective of respondents.
Presentation of the data utilises the Weberian concept of verstehen – a process of
“interpretative understanding” (Charmaz 2003) used “to grasp or comprehend the
meaning intended or expressed by another” (Elwell 1996). Verstehen is considered
to be rooted in interpretivism and hermeneutics (Schwandt 2000). The process of
interpreting or understanding (of achieving verstehen) used by this researcher is that
which is allied to the interpretevist tradition rather than philosophical hermeneutics.
That is to say that Weber’s approach of understanding the subjective meaning and
intent of the actor – “getting inside their head to understand what he or she is up to
in terms of motives, beliefs, desires, thoughts” (Schwandt 2000, p192) has been the
researcher’s aim. This view of verstehen has been linked to Husserl’s “intentional
object” – that is the object as meant, as intended in the acts of thinking,
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remembering, willing and imagining (Natanson 1963, p283). This contrasts with the
Heidigger inspired (Schwandt 1998) perspective of philosophical hermeneutics
where understanding is participative and meaning is negotiated mutually in the act
of interpretation, the researcher being unable to remain an uninvolved observer and
instead being active in the construction of meaning (Schwandt 2000).
3.13 Presentation of the Data
Verstehen takes the participants’ subjective meanings as the starting point for
enquiry (Parkin 1982); quotations directly from interview transcripts are central to
this approach and are employed to illustrate such meaning.
3.14 Triangulation – Documentary Analysis
As part of the researcher’s triangulation strategy, documentary analysis was used to
corroborate accounts and highlight differences within the interview data. In this way
analysis of documents has been of particular value in evaluating key areas central to
the research questions:
When titles and terminology associated with specialisation entered the
professional language of podiatry
When differentiation and areas of specialised practice became part of
podiatry’s way of working
Timelines for the emergence of specialised practice
Grading and banding structures linked to different specialties as a reflection
of status and remuneration
The degree to which professional credentials have been linked to specialised
practice
3.14.1 Documentary Sample
In addressing these particular areas, the “population of available documents”
(Hodson 1999) includes historical texts, Society of Chiropodists and Podiatrists
archives, job advertisements, job descriptions, pay scales, course content in diabetes
podiatry education and editorials in professional journals (see section 3.4). In order
to address the historical and evolutionary aspects job advertising within historical
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journals was selected as an appropriate resource; allowing for the analysis of
advertising covering many years.
Each job advertisement may have referred to one or more posts. Where no indication
was given an advertisement was coded as a single occurrence. Where job advertising
included more than one post indicated by a plural (for example “Lecturers in
Podiatry”) this was coded as two posts and where numbers of posts were stated each
post was counted separately. The numbers of included advertisements, excluded
posts and advertisements were not counted. The analysis focussed on clinical and
educational posts in the public sector.
The historical journals used included one independent publication and the official
journal of the largest chiropody professional organisation:
The British Chiropody Journal 1933 – 1988 (British Association of Chiropodists,
Inc.) which became the British Journal of Chiropody in 1965 was an independent
journal, having no official affiliation to any chiropodial professional organisation.
Franklin Charlseworth was editor from 1946 to 1949 and again from 1956 to his
death in 1963, the other editor during these years being Frederick. A. Drew (Berry et
al 1989). J.C. Dagnall became editor in 1963 and immediately changed the name of
the journal to the British Journal of Chiropody; He continued as editor for twenty
five years until the demise of the journal in December 1988.
The Chiropodist (1924 to 1990) was the “official organ of the Incorporated Society
of Chiropodists” up to October 1945, the copyright being then taken over by The
Society of Chiropodists when amalgamation with four other professional bodies
brought into existence The Society of Chiropodists. In January 1989 The
Chiropodist’s title was extended to include “incorporating the British Journal of
Chiropody, formerly the British Chiropody Journal” and Colin Dagnall became a
regular contributor to the journal, having his own page each month. In 1998 the
sub-title “Journal of British Podiatric Medicine” was added; this was to become the
official title of the journal from 1991. Subsequently the coalescence of three bodies
(The Association of Chief Chiropody Officers, The Podiatry Association and The
Society of Chiropodists and Podiatrists) in 1997 led to a review of their respective
journals. In 1998 The British Journal of Podiatry was created to disseminate
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research and scholarly material while Podiatry Now continued the news
dissemination and advertising functions for the new professional body.
3.14.2 Documentary Data collection
These journals form a permanent record, representing a significant historical
resource. In selecting an independent journal in addition to the “official” journal of
the largest professional body in chiropody and podiatry the researcher’s aim was to
reduce the effects of institutional bias. A hand search of the historical journals was
undertaken. Using a thematic approach, announcements of new appointments,
appointments available and situations vacant were scrutinised for references to
clinical specialisation in diabetes or any other defined “specialised” clinical area.
The year of publication for each data entry and information on the identity and role
of the advertiser were recorded during data collection. This chronological approach
allows presentation of the data illustrative of emergence and changes over time.
Going beyond a simple word-frequency count, identified advertisements were read
and summarised. This facilitated comparison with data derived from the focus
group and key actor interviews, useful in eliciting areas of concordance and
difference.
The British Chiropody Journal (later the British Journal of Chiropody) was hand
searched throughout its history, covering fifty years (1933-1988), with the exception
of the December 1971 edition, which is unfortunately not within the collection. The
first mention of specialised activity was the proposed establishment of a research
group in 1949. References to specialised clinical activities began to emerge in 1954
and were evident, though sporadic until the demise of the journal in 1988. This
guided the time-frame for hand searching The Chiropodist, which began with the
journals published in 1944 (the earliest reference to specialisation in the first journal,
minus ten years). The Chiropodist, followed by The Journal of British Podiatric
Medicine and currently Podiatry Now form a continuation of publications to the
present day.
3.14.3 Inferences
The author has used overt and latent references to specialisation within the text as
content indicators, inferring the existence of specialisation. The units of analysis
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utilised were derived from the researcher’s proposed definition of specialisation and
recognition of specialist status which were elicited through her concept analysis (see
section 1.6). These units are:
Status Image Title Differentiation Client Groups
Activities Roles Functions Education Credentials
Knowledge Skill levels
Themes which contained any of the above units were elicited by in-depth reading.
The analytical constructs which underpin the researcher’s inferences are rooted in
theories of the sociology of the professions relating to specialised practice (discussed
extensively within the literature review); areas pertaining to the professional project,
legitimation and drivers for specialisation being particularly pertinent.
3.14.4 Analysis of the Documents
Advertisements were analysed in order to make explicit:
The chronological advertising of posts, their associated professional titles
and required credentials
The chronological advertising of posts in different specialist areas
The grading (from 1976) and banding (from 2005) of posts in different
specialties
Quantitative analysis, utilising these aspects as frequency content indicators allowed
inferences to be drawn regarding the advent, change over time and status of
specialist posts.
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FINDINGS AND DISCUSSION
Findings from the process of enquiry flowed into three main areas. These are
presented and discussed individually, beginning with charismatic authority and
medical patronage (4.0), followed by title (5.0) and concluding with specialisation in
diabetes podiatry (6.0)
4.0 Charismatic Authority and Medical Patronage.
Themes of charismatic authority and medical patronage featured strongly throughout
the data.
4.1 The Role of Charismatic Authority in Developing Specialist Practice
Throughout the accounts of those involved in establishing and developing diabetes
podiatry the importance of personal charismatic qualities is repeatedly emphasised.
Indeed the integral nature of the practitioners’ charisma forms a repeated theme in
the accounts of all respondents; participants illustrate how charismatic qualities have
been important historically and how they continue to impact at every stage and level
of contemporary specialised practice.
4.1.1 The Emergence of Diabetes Podiatry as a Specialty
Although participants indicated that podiatrists had been employed in diabetes units
since the 1970s, they considered that these earliest podiatrists working in diabetes
could not be viewed as real specialists:
“As a real em [sic] entity, I know a few in this trust who have had podiatrists
working in the diabetes unit and working at you know as a podiatrist in diabetes but would I call them specialists? I probably wouldn’t do. But
they’ve had them working here since the s [breaks off] well, back as far as the seventies. So there’ve been podiatrists working within the diabetes team,
but I wouldn’t have called them specialist.” [MP 393-397]
“… I don’t think by any stretch of the imagination they were specialists, they
were just people who dealt with people with diabetes and they worked in a clin [breaks off] they had a lot of people with diabetes so ooh – I must be a
specialist.” [CG 640-643]
The initial role for the podiatrist within the diabetic foot team centred on
debridement:
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“They knew how to take the callus off an ulcer and stuff like that, but that’s
all they tended to do every week, in the early days, because that was the knowledge that was out there.” [MP 399-400]
“… the key role at that time was very much debridement to, to a greater or lesser extent at that time wound care wasn’t seen to be erm [sic] under the
province of podiatrists, it was more nurses were more involved with supervision …” [JH 114-118]
As one diabetologist recalled, it was their debridement skills which brought
podiatrists into contact with medical doctors and thence into the diabetes team;
leading eventually to a greater appreciation of their utility:
“… the doctors involved don’t particularly have the [debridement] skills –
although when I was starting, I was having to, when I first had the foot clinic in the early 90s I was actually wielding the knife and it was very clear that
what we needed was someone who was skilled at that and that’s the podiatrists, that’s what they were doing to begin with. But now there’s such,
such a wider field – it’s not just the wound management but the offloading and the biomechanics, it’s just so much. They’re trained, therefore they
should be er, er [sic] leading the services.” [AT 6-13]
The gradually developing evidence base for those skills podiatrists could bring to the
diabetic foot team – specifically offloading, sharp debridement, vascular and
neurological assessment; coupled with the commitment, motivation and thirst for
knowledge of the podiatrists working in diabetes all played a role in the
establishment of diabetes podiatry:
“I think erm [sic] the evidence of dealing with, the evidence of dealing with certain complexities of foot ulcers, Charcot joints, infection …but I think the
early days what made the podiatrist erm [sic] really part of it is that the beginning of the realisation of what we could bring to the arena of care,
offloading primarily, scalpel debridement another one erm [sic] and slowly aspects of vascular assessment, neurological assessment and, and , and by
stealth and by time and by doggedness erm [sic] and also by alongside that courses for podiatrists and chiropodists, there were around they weren’t
necessarily validated or accredited in the universities, but there were a number of post registration courses available, notably the run by the Society
which you could drive a horse and cart through academically but it attracted good speakers, people were very thirsty for new knowledge and there was a
genuine erm [sic] huge motivation and er [sic] or amongst a lot of podiatrists who really felt they could make a difference in diabetic foot
care.” [JH 111-129]
“Oh again the results, the published results from centres like Kings, like the Manchester diabetes centre, the Blackburn, the Exeter and old, old Ken at
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London Foot Hospital, you know the work just was assimilated I guess” [PL 231-233]
4.1.1.1 Icons and Role Models
In speaking of the emergence of diabetes podiatry all but two participants
highlighted the importance of key individuals who were innovative in practice,
establishing specialist skills which differed from those of other podiatrists; and who
– via their interactions, publications and presentations raised the profile of diabetes
podiatry as a specialised area. Those considered to be early “icons” were mentioned
specifically:
“ You know there were a few icons like Ali [Foster] and she knew, well bless her she was, she is, really is iconic and putting us on the map …” [SS 59-61]
“… [Althea Foster] was one of the early pioneers in so far as the techniques for plaster use, use of plaster casting apart from Paul Barnes’ work and
Hanson’s disease and all the rest of it, erm [sic], she, she was quite early on in the UK as far as podiatrists getting their hands onto plaster casts and
expanding scope of practice. She was a bit of a pioneer there.” [JH 28-32]
“I think that reality, I think the podiatrists play a pivotal role in it and I think
if we look back to 1989 paper that Alistair [McInnes] was involved in with Mike Edmonds et al, that St Vincent’s’ paper, if you look back to that paper
you’ll see that they defined the roles of the podiatrists, doctors, nurses, whatever.” [SS 69-72]
“… I think the first real specialist, specialist role in diabetes were the few that gained Chief grades as a specialist. There were a few Senior I
specialists, but I think the true specialist post, when most of the folks that you now know as leaders em [sic] gained Chief posts in, generally in hospitals,
hospital settings and obviously, one of the most obvious ones is Ali [Althea Foster]. Em [sic] interestingly Alistair McInnes was known as a specialist,
well he was working in the health service but then went into education…” [CG 643-648]
Such was the impact of these individuals that the appointment of Althea Foster was
highlighted by one Faculty of Management respondent as the start of diabetes
specialist podiatry:
When I took on Ali Foster in the Kings em [sic], I employed her in the middle 1980s, so that’s when her role started off, so I think that’s clearly when it
kicked off” [Faculty of Management 334-337]
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Those considered to be pioneers in diabetes podiatry showed innovative approaches
to skill acquisition, funding and accessing education:
“Another key moment was when I had a long chat with Ali Foster and we were talking about how she’d got certain skills and where did she get them
and getting bits of money, self-funding, off to America. I remember asking her to talk about where she got her plaster casting techniques from and the
skills, and it was when she spent time in the States. I thought we can hardly, we can hardly have that as part of a p [breaks off], an on-going
programme.” [JH 11-16]
Thus by importing what they had learned they influenced practice, extending its
scope and establishing new, specialised activities which differed from those of other
podiatrists. Knowledge was then disseminated through conference presentations and
authoring books, sometimes with medical co-authors.
“…the fact that there have been a few of us who have been very em [sic]
active in research have also allowed us to present at national and international meetings which has then raised the awareness of the skills of
podiatry to the point now where I would say that the podiatrist is actually pivotal in all of the diabetic foot clinics.” [CG 125-129]
3: “Also as 8 was saying there’s certain eminent people for diabetes care that you gain confidence off by going to diabetic conferences, people like Mike
Edmonds for example, Ali Foster, you know it’s reassuring to go to these conferences and find that actually you are on the right track
6: Mmm [nodding] 3: it gives you confidence and so pioneers like that and some of the books that
they produced you know just simple things like that little diabetic book that Mike Edmonds and Ali Foster put out I think that was a big help to me when
they produced that to tie in what I already knew and give me the confidence to say well actually I do stage it in that way, and I do have that thought
process …” [Expert Reference Group 771-779]
Against a climate of medical distrust for podiatry engendered by the podiatric
surgeons’ actions in establishing their rights to undertake foot surgery; the combined
effects of key individuals and exposure of British physicians to good practice in
diabetes podiatry which existed in America allowed the continued development of
diabetes podiatry:
“I think er [sic] pioneers like Ali Foster. I think the American influence,
when em [sic] Malvern surgical podiatrists were kind of em mmmm [sic] [sighs]. The prevailing [pause] culture at that time was one of, a bit of
antipathy towards podiatric surgeons from the medical mafia diabetes arena for a long time, and then when certain key people, Andrew Boulton and
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others went across, formed good relations with people like Larry Harkless from San Antonio and others, they realised that what they were doing was
sound and really good practice and that helped podiatry big picture a lot” [JH104-110]
These early “icons” in diabetes podiatry acted as role models, and in a departure
from the norm in podiatry, worked in a team setting:
“… some of the drivers were er [sic] people who became sort of erm [sic]
role models, er [sic] and, and I think diabetes, the team approach and understanding of the role of the team approach to diabetes care was kind of
loud and strong through Harry Keane, concepts of shared care, concepts of diabetes centres and that sort of thing.” [JH 155-159]
4.2 Medical Patronage
Working in a multi-disciplinary team (MDT) may have represented the first
exposure to podiatry for many physicians. It appears that within diabetes podiatry,
medical support for podiatrists began in this multi-disciplinary team environment:
“…the development of the MDTs in em [sic] Kings and Manchester em [sic] particularly, em [sic] in the early eighties er [sic] provided a ripe
environment for those who were interested to develop and then for other folks around the country, particularly consultant physicians who are
interested in the foot and recognised that there was a problem with the foot, actually allowed people with a real interest in diabetes to gravitate to them.
In that environment I think podiatrists then em [sic] were in some instances were able to develop their skills which were slightly outside the normal skills
that they were taught at undergraduate level or, or practicing within the community service. I think the recognition of skills, once again by vascular
surgeons em [sic] has also pushed some of the boundaries.” [CG 119-125]
As CG (above) points out – for podiatrists, working within the multi-disciplinary
team not only represented a further opportunity to extend their skill set, it also
facilitated medical recognition of their existing skills. JH also highlights the
opportunities for informal education which membership of the multi-disciplinary
team at this time afforded:
“… probably a lot of skills and knowledge and attitudes that are part of the competence if you like of that role, probably came a lot from working in the
hospital team setting erm [sic] to begin with. And that was from informal education from joining in lunchtime chats that the team approach to diabetes
care. So the multidisciplinary team approach, the notion of shared care, where podiatry, chiropody was seen as a sort of erm [sic] add on in those
days, as opposed to being an integral part these days, was part of my steep learning curve about a broader aspect of diabetes …” [JH 71-78]
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Diabetologists working in the first MDTs recognise their role in the development of
diabetes podiatry:
“I have facilitated that, em [sic] the progress itself has been made predominantly by the podiatrists, as such, so, but I think one’s allowed it to
progress as it were in a very sort of warm, warm, supportive environment as such.” [IM235-237]
The multi-disciplinary team approach to diabetic foot disease became enshrined in
NICE guidelines, in this way health policy has served to formalise the multi-
disciplinary structure of the diabetic foot team:
“National policies and NSFs and all the national guidelines that you have to, as a service you have to be responsive to them otherwise you can’t be seen to
be meeting the NICE guidelines and the multi-disciplinary team that they set out as the ideal em [sic] so because that’s you know been developing in the
2000’s its changed the way that we work in podiatry, you have to be able to be seen to be working towards something that, that’s recognised as standard
approach.” [Expert Reference Group 346-350]
Medical acceptance of and support for podiatry within the diabetes team was gained
by a few key podiatrists. Though historically podiatry had not been a team
orientated profession, these individuals were able to function within the multi-
disciplinary team environment. By demonstrating knowledge and confidence
coupled with ability in presenting they secured the support and acceptance of
diabetologists and then the wider medical team:
“The drivers. Erm [sic], key, key people along the way erm [sic] a lot of people were concerned about levels and quality and what made somebody a
- and it still is the question today, what makes a specialist podiatrist. I think key players who, who erm [sic], I mean once upon a time Ali Foster, myself
and maybe one or two others were the kind of sole representatives, not because we were so wonderful but we were the drivers of things because we
could hold our own in that environment I suppose, we could get up and speak and, and slowly, and I like to, I mean I, it’s a bit immodest of me but I think
particularly that was much more so of Ali Foster, erm [sic] when they were accepted as members of the diabetes team and presented well and knew their stuff they were then accepted by the other members of the medical team and
they then helped to support podiatrists …” [JH 133-142]
Thus specialisation in diabetes podiatry may have been a manifestation of medical
influence within the profession of podiatry; or having been exposed to specialist
practice, podiatrists may have sought to establish diabetes podiatry as area of
specialty. Were podiatrists emulating medical structure in order to extend their scope
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of practice and gain status, advancing what Larson (1977) would call their
“professional project”? Were medical doctors using podiatry to ease their workload
and shed their “dirty work”? Following the St Vincent Declaration in 1989 and
founded on the gradually developing evidence base for key podiatric skills, were
both groups focussed on and working to reduce amputation and ulceration rates? It is
of course entirely possible that all of the aforementioned are true, in which case both
groups would view the advent of specialised diabetes podiatry as a mutually
beneficial arrangement, effectively guaranteeing continued support from both
parties, a representation of Weber’s “elective affinity” (see section 1.8.3.3). At this
time the increasing diabetic population and the extension of the diabetes podiatrists’
skill set represent further drivers for specialisation, being events which Abbott
(1988) has highlighted as key precursors for differentiation.
4.2.1 Combined Effects – Charismatic Authority and Medical Patronage
Within the accounts of those who sought to establish themselves as specialised
diabetes podiatrists, charismatic qualities such as confidence and tenacity feature as
the means by which medical contacts were established:
“… tenacity I think would be the most, em [sic] obviously had an interest in diabetes right from undergraduate level, em [sic] and in the days that I
qualified, which is quite a number of years ago now, the specialism in diabetes s actually wasn’t formed. The, em [sic] King’s was just about
coming, em [sic] about three years after I’d qualified, so, so for me em [sic] I had an avid interest in diabetes, so I made sure that I’d got to know, I
worked in quite a few hospitals and wherever I worked I went and introduced myself to the endocrinologist and diabetologist and said look, I’m
a podiatrist and or chiropodist in those days, em [sic] one of the things we can do is help you with patients who have ulcers for example, because we
can make insoles as they were called, or appliances in fact I think we called them. Em [sic] and we are very good with a knife, we can sort of cut away
some of this dead skin and things. So that, that’s sort of how it all started and I was fortunate enough to be tenacious enough to go up to people like
vascular surgeons and say hi, Colin’s3 the name, feet’s the game [gestures as
if shaking hands with someone] what can we work together. Em [sic] and
as, as, as then I also formed an interest in vascular surgery or, or peripheral arterial disease and started working alongside the vascular surgeons, who
recognised immediately the skills I had with a scalpel and started putting me more and more in to, to their repertoire and that’s really how I sort of got
into it I guess.” [CG 16-33]
3 A pseudonym
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Diabetologists acknowledge that the drive to establish and develop joint
medical/podiatry clinics came from the podiatrists:
“… right at the very beginning it was Mary Blundell who sort of said to me in a sort of inspired note … she said you know this is crazy, she said, you
know, why don’t we see them together in my place? And this is how the foot clinic was born really. Because then I went to see, we, went we started off on
Thursday morning there and that’s how it started in May 1981.” [IM 538-546]
“So I had a number of community podiatrists who came in to work with me
and it would be a different one every week and so on, which was not great. And then I, then there was em [sic] the lead podiatrist was, developed an
interest and he came along and said well, why don’t we get some consistency into the clinic and em [sic] he did quite a lot of work with me and then er
[sic] and that produced consistency …”[OM 27-33]
Excepting the Skills for Health informant, the accounts of all respondents featured
key themes around medical patronage and the charismatic qualities of the podiatrist -
which they identify as having influenced the establishment and subsequent
development of diabetes podiatry as a specialist area of practice. These recurring
themes were:
Medical support and acceptance of what diabetes podiatry could offer
Networking and educating others about diabetes podiatry
Forging good working relationships with others
A proactive approach
“… if you work with somebody in secondary care, a consultant and the attitude of the consultant and their willingness in acceptance of us as a profession and
what we can provide and having good working relationships with those people and just erm [sic] networking with other professions, professionals to show you,
to show them what we can actually do, I think that’s had a big influence as the determination of er [sic] individual podiatrists with in an interest to push the
boundaries a bit and em [sic] certainly in our Trust we had a group of us that were interested in proving that the diabetic foot clinic could work and we, we
gave our service for free for 6, 6 months to show that it could work and it did and convinced people that it worked and so that was a big influencing factor and
so I think we underestimate how proactive we are as a profession at times, we’re quite good.” [Expert Reference Group 355-364]
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4.3 Change Over Time All respondents agreed that diabetes podiatry has changed over time:
“I think we’ve moved on massively in the last, well sort of look at me, 17
years ago it was, it was you know I was just getting off the starting block and now I think we’re no longer the Cinderellas, within that, you know, team.”
[SS 88-90]
Clinician respondents highlighted the way in which roles formerly undertaken by
medical doctors were now within the remit of the specialist diabetes podiatrist. This
may be a manifestation of medical practitioners reducing their workload or represent
their shedding of low status “dirty work”:
“I think you could also add in sort of medical proper problems such as painful neuropathy, Charcot - that sort of diagnosis and management of
those for the lead specialist podiatrist.” [Expert Reference Group 429-430]
“If you look at that from 1989 and look at it now, those boundaries are very,
very blurred, for example I prescribe antibiotics, offload the patient, I take their blood pressure, I do cardio-vascular risk factor assessment with them, I
look at wound care, I mean sometimes I think our skills as podiatrists have extended to be inclusive, whereas I think, certainly in terms of medics, very
few medics have the same varied practical skills that the podiatrist has, but podiatrists I think have gained some of those holistic medical triage skills
and assessment skills …” [SS 72-78]
This development and extension of diabetes podiatrists’ roles requires them in turn
to pass on some of their traditional activities to support workers; representing a
chain of task shedding:
“Em [sic] you’re also getting some of the support workers now taking on the role of em [sic] screening. Originally screening in the early days was seen
as a very specialist role and now obviously, you know people are accepting that as you develop and move on you’ve got to leave things behind you, but
you’ve got to make sure that as you’re leaving things behind you’re passing it on to capable people so, a, again some clambered and clung desperately to
everything we could and now they’re realising that you’ve got to let certain things go. And that’s about educating other people to take on those roles, so
I think that’s an important side of it.” [MP 100-107]
The Skills for Health participant accepted in principle, the involvement of
appropriately trained assistant grades in treating people with diabetes:
“I’ve actually said that you need to be a podiatrist to deal with diabetes
patients, but that’s technically not true, cos [sic] if, if you’re a, a patient who hasn’t got any of the real complications associated with diabetes, but needs
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regular treatment, then why shouldn’t that be somebody who’s trained up,
who’d be an assistant practitioner?” [BL 687-691]
4.3.1 The Impact of Confidence “Pushing the Boundaries”
Confidence - “having the bottle” to direct medical intervention and present at
national and international levels is the key attribute identified within those
individuals who have “pushed the boundaries” in diabetes podiatry:
“I think it’s really by a, a, and it’s horrible to say this but I think it’s been a few key individuals really pushing away and pushing the boundary, and
actually working almost outside our normal scope of practice and actually having the bottle to go up to people and say, you know you’re going to take
that toe off, I don’t want you to impinge on the plantar surface, I want you to do a dorsal incision, go along the top of the metatarsal, take it out and leave
the metatarsal exposed, remove the dorsal tensor, I want you to leave the plantar tendon, long flexor tendon attached please at such and such, so we
can then rehabilitise [sic]. …Yeah, and I think there again em [sic] as I’ve said and you’ll hear this over and again on the tape, the fact that there have
been a few key individuals who stand up at national and international meetings and say, right OK we’re not just gonna [sic] say we’re good, but
actually these are our amputation rates, and I’ll talk for us here, having just finished an article with [name of diabetologist] that’s going to BMJ, em [sic]
we now have 11 years prospective data on our amputation rates, we now can show that since the establishment of an MDT, when I came here, we now
have the lowest amputation rates in the world.” [CG 169-175, 190-196]
In order to “push the boundaries” though, certain requirements were identified:
“…if you’re a consultant in diabetes then you’ve got to have the clinical expertise, you’ve got to have the clinical input and you’ve got to have the
clinics to see the patients in, otherwise it’s not about pushing the boundaries.” [MP 170-172]
Research, publication and presentation activities were highlighted:
“I think you’ve got things like the Diabetic Foot Journal haven’t you so
you’ve got a body of people who’ve like we’ve just had the Diabetic Foot Conference so you’ve got a body of people who’ve done the research and are
going out and doing lectures and the publications.” [Expert Reference Group 369-371]
In presenting and publishing their work charismatic leaders acted as role models,
imparting confidence and reassurance:
3: “Also as 8 was saying there’s certain eminent people for diabetes care that you gain confidence off by going to diabetic conferences, people like Mike
Edmonds for example, Ali Foster, you know it’s reassuring to go to these conferences and find that actually you are on the right track
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6: Mmm [nodding] 3: it gives you confidence and so pioneers like that and some of the books that
they produced you know just simple things like that little diabetic book that Mike Edmonds and Ali Foster put out I think that was a big help to me when
they produced that to tie in what I already knew and give me the confidence to say well actually I do stage it in that way, and I do have that thought
process, but never really thought about it in as clear a fashion maybe as they presented it …” [Expert Reference Group 771-779]
“I think at Kings it was because they couldn’t ignore the work that we were
doing, because we were one of the very, very early foot clinics and after a couple of years we had demonstrated a 50% reduction in major amputations
and we were all very, very conscious of the need to promote the profession, you know and we had a lot of publications, a lot of presentations at Diabetes
UK and so I guess we won the respect of our colleagues and that was how it [practice] changed” [PL 52-58]
4.3.2 Challenging Practice
Respondents linked the ability to challenge the practice of other professionals to
professional development within the diabetes team. The implication being that this
not only provides a valuable learning environment but in some way also confers
legitimacy to the diabetes podiatrist:
“I think too one of the big things is those of us who have been fortunate
enough to have for whatever reason found ourselves in a dynamic, supportive em [sic] foot team have been able to develop skills of presenting
patients to other professionals and actually fighting the cause which is saying to some [medical] consultant I do not agree with you, you are wrong
[as if speaking to consultant]. Em [sic] that has taken about twenty years I think, really because I think there’s only been 2, 3, 4 people within the UK
who’ve had the right sort of environment to develop those skills.” [CG 134-140]
Knowledge, skills and particularly communication skills are considered to be pre-
requisites for challenging the practice of others:
“And then when you actually come to stand up to people and you challenge
them and be that change agent, it’s funny to see that years ago we felt we can’t say that to the GP, the GP would get upset or the doctor would get
upset and now I think there’s more parity but I think the parity only comes if you have not just the knowledge but the skills and those communication skills
especially.” [SS 83-87]
These accounts provide an illustration of the way in which once established,
charismatic authority tends to challenge the traditional or rational-legal authority
which facilitated its very evolution. For Weber the resolution of this form of
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challenge is achieved through a process of “routinisation” (discussed in sections
1.10.7 and 4.8.3).
The need for “vision” in order to challenge practice was highlighted and, echoing
the theme of responsibility, it was also pointed out that in making such challenges to
practice diabetes podiatrists have to be willing to disturb the status quo and also
willing to accept the consequences of having disturbed it:
“ … I’m interested in, in challenging and being a change agent which
doesn’t always make you very popular, but you’re not here to be popular are you, you’re here to actually create change and sometimes contention creates
havoc not just change.” [SS 200-203]
“I mean you’ve got to be willing to move things forward, you’ve got to have
vision, you’ve got to be willing to send up flack, em [sic] you’ve got to be willing to try new ideas safely er [sic] and incorporate those into your
clinical skills.” [MP 516-519]
Some diabetes specialist podiatrists clearly viewed part of their role as changing not
only clinical practice but also governance structures:
“[diabetes podiatrists are] The clinical champion that crosses boundaries and certainly from my role I, I’m talking about not just what I do and seeing that
evidence in practice, but also knowing what my colleagues are doing who work at a similar level. And we do cross boundaries between vascular,
neurology, GP, em [sic] district nurses, practice nurses, we really do provide that conduit, which very often the patient fell between two systems of care,
now we can pick them up because we’ve got very tight governance structures in, in place in terms of care pathways and what-have-you, where the
patient’s picked up in community and I’m seeing them in 24hours if they’ve got a foot ulcer and if I don’t see them I’ll raise a critical incident, because
we really have to enforce it, I mean it’s not about upsetting people, upsetting the apple cart, it’s about giving patients the care that they require …” [SS
97-107]
4.4 The Continued Role of Charisma
Participants illustrated the on-going effects of charismatic authority, beyond the
initial establishment of diabetes podiatry, illustrating how it continues to impact at
every stage and level of contemporary specialised practice.
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4.4.1 Succession
The phenomenon of succession was discernible in the transition from early icons
who established diabetes podiatry as a specialist area, to later “key leaders” and
“champions” who sought to develop diabetes foot care:
“I think the goal posts have changed hugely, in the last ten years, let alone the last twenty years. Twenty years ago diabetes specialists podiatry - yeah
you defend it, who, who was it? You know there were a few icons like Ali and she knew, well bless her she was, she is really is iconic and putting us on the
map, erm [sic] I still think we’ve got a long, long way to go, but I think there are quite a few coming up champions there for diabetes that are willing to
stick their head above the parapet and be counted and have the actual ability to do that, we’ve got a long way to go yet though.” [SS 57-64]
Contemporary leaders have challenged the practice and models of the early “iconic”
individuals and seek to have a broader, cross-professional influence on standards
within the diabetic foot arena:
“We are driven. Louise[Stuart] and I are, I mean we’re nuts both of us, but
we are really driven at what we do and, and em [sic] you know it, that’s what I’m saying you know Ali [Foster] was a, I, I love Ali to bits, I gave a
witness in her trial so, I mean she’s a real personal friend em [sic] but sadly and this I, I’ve said this to Ali’s face and I’ve said it to Mikes’ face, you’ve
monopolised the diabetic foot, it’s either the wak [sic] or the wams [sic] – we at Kings or we at Manchester and that’s the model and that’s what it
should follow, and we said and I said I don’t believe that to be true, because there are loads of models out there, just cos [sic] what you’re doing you
think’s right doesn’t mean to say it is em [sic] and to have a matriarch of the diabetic foot and Ali has done marvellous things em [sic] I think the time has
changed and there are now a couple of key leaders or a few key leaders in, in the diabetic foot who are equally driven as Ali but are more, have a wider
view and say actually we’re not going to tie ourselves to an institution i.e. Kings or Manchester we’re gonna [sic] look at the diabetic foot full stop,
whether you’re a nurse whether you’re a doctor, whether you’re a podiatrist and we, we’re wanna [sic] look at the whole thing and we create a right
environment for people to progress and develop as, as clinicians as researchers as educationalists within that role. And also to set the
standards, cos [sic] nobody was setting the standards.” [CG 1042-1058]
While the Society of Chiropodists and Podiatrists’ Faculty of Podiatric Medicine and
General Practice aims to provide an arena in which the charismatic leaders can be
heard and exert influence:
“So all the movers and shakers are on the faculty one way or another er
[sic] and we try and give them a voice and make their opinion heard.” [JB 55-56]
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…the diabetes podiatrists express frustration with the Society of Chiropodists and
Podiatrists and ally themselves more closely to the diabetologists and surgeons, who
may represent a more powerful sponsoring elite:
“the way in which specialists have developed is not through our own
profession it’s been through medics and surgeons, it’s by them recognising our skills it’s not been from our Society recognising the skills, it’s been as I
say from those within secondary care that have actually said – these guys have got skills, let’s teach them how to do more, let’s give then more
responsibility, let’s allow them to develop, oh gosh yeah we can leave the foot in their hands, we don’t have, you know fine we do, there are some bits
they shouldn’t be doing or can’t do em [sic], but let’s leave more and more.” [CG 777-784]
4.5 Continued Medical Patronage
The role of medical patronage in the further development and dissemination of
specialised diabetes podiatry was acknowledged. Indeed informants pointed to the
dependence of diabetes podiatry upon medical support:
“… some of the drivers were key physicians who erm [sic] who appreciated what podiatrists were doing and were very much key guys behind and
interested in diabetic foot care, bearing in mind that, you know, diabetic foot care clinic up and down the country, what if you’ve got a good one, the
chances are you’ve got a consultant who’s interested in diabetic foot care, if you’ve got a poor one the chances are the consultant isn’t so the key, pivotal
positions in diabetic foot care are interested physicians and key guys along the way, some of the surgeons too, Patrick Weindorf – podiatric surgeon in
Liverpool, Mike Edmonds – physician at, at Kings, Andrew Boulton – at Manchester, Matthew Young in Edinburgh, Ewan Masson in Hull, erm [sic]
the number of key guys, Bob Young in Salford, key physicians who have helped enable them, so some of the drivers are key physicians …” [JH 145-
155]
…though medical consultants still express ownership over the diabetic foot teams:
“And, and I think in a way that, that [ownership issue] would have to be Addressed because it’s [pause] and the NHS I don’t think has addressed this
yet. Because if, you know it’s very much now the flavour of the multi-disciplinary team and the multi-disciplinary conference as such, but at the
end of the day when there’s, you know on the name on the bed is the consultant and the name in the clinic is me.” [IM 523-528]
… which may in part be based on their varying activities in raising the required
funding to support the team:
“… so I raised the funding to, to, to bring Neil Baker from Southampton to Ipswich. Now it was all soft money and it was based on me doing drug
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company studies and various bits and pieces to bring that together. And I also brought in a specialist nurse to work alongside the podiatrist … and
again all that money was raised through drug-companies.” [OM 48-57]
Once again networking and charismatic authority, promoted and supported through
the patronage of key physicians, influenced the dissemination of models of clinical
practice which involve podiatrists:
“It’s those sorts of things that have actually I think changed the way in
which a lot of people now look at podiatrists, because the medics talk to other medics, and surgeons talk to other medics and you know, I’ve certainly
been at places where, George come and meet [says own name], he’s our podiatrist, now you’ve got podiatrists do have a chat with [says own name]
about what we do and how we do it, so on and so forth. Em [sic] and that’s been very useful, certainly locally now for example the Vascular Surgeons
involve the podiatrists in [name of another trust], they didn’t do that four years ago, it’s only when I met and had a chat and all of a sudden now
they’re using them all the time. And I think that’s true for a number of other folks around the country who’ve been involved.” [CG 179-188]
So fundamental is medical support in this process that lack of it was consistently
highlighted as a barrier to development:
I think the barriers we’ve found over the years are er [sic] you might want to
progress something but are stymied by the individual consultant. [Expert Reference Group 383-384]
“I mean you’ve gotta [sic] consider people like Mike Edmonds and Matthew Young and, and em [sic] Gerry Rayman … and Phil Wiles here, there are a
number of consultants who are, who are passionate about the diabetic foot, but equally there are a number that are ambivalent or not even ambivalent,
they’re completely nah [sic] I don’t want to know the diabetic foot. You know in, in the area that I’m working now 10 miles down the road, less than
10 miles down the road there is no clinical champion for diabetes, there’s no specialist in, in the community the podiatrists are running round like
headless chickens trying to do the best they can without any infrastructure to manage these patients, its criminal, and that’s going on across the country,
we talk about multi-disciplinary specialist teams, how many are there, you can name them one hand, yeah and they talk about them as if they’re the
icon, they’re 21 years old …” [SS 142-154]
A lack of exposure to and poor knowledge of diabetes podiatry were highlighted as
the cause of difficulties with GPs. This lack of exposure would offer an explanation
of why GPs appear to have been less susceptible to the effects of diabetes
podiatrists’ charismatic authority:
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3: In our patch they [GPs] really alienated themselves from community services
because one of the GPs thought it would be a good idea to send a questionnaire out about em [sic] their knowledge of community services and
displayed a distinct lack of knowledge and were actually quite insulting about what we did and, we fared quite well er [sic] compared to others and
some of the comments were very disparaging, so yes I think there’s education issues there that er [sic] [tails off]
2: Well the new GPs are now placed with us as part of their rotational training 6: Mmm
2: er [sic] its, it tends to be those who are coming up into the times of senior partnership, the old ones have taken early retirement cos [sic] they wanted
to escape and they’re now into the late 40’s early 50’s and they, they are of a, of a school of training where anyone who wasn’t a doctor has no brain
cell to rub next to the other one and unfortunately the, the very young ones who, the new ones who come are very proactive GPs have often had
exposure to us professionally and they’re a bit more informed so I think there’s just this 15, 20 year hiatus that we’ve gotta [sic] go through until
they get to be the senior partners Gen: [laughter]
2: which is an awful thought, but the senior partners run the budget, the senior partners
5: Yeah 2: dictate what is happening
5: it’ll be alright in 15, 20 years [laughter].” [Expert Reference Group 1315-1334]
Where diabetes podiatrists work in primary care, communication with GPs tends to
remain on a more formal basis:
“ … I thought if took up a primary care post that my biggest ally would be the GPs, is it [pauses and indicates suppression of expletive] my biggest ally
are the practice nurses, the district nurses the administrators and they’re the ones that get something done for me, the GPs inevitably I, I have to write to
or phone them up and say as per such clinical guidance I would much appreciate you putting the patient on clindamycin or whatever it is, but the
GPs don’t normally use those drugs and they’re a bit cautious” [SS 283-289]
Education for GPs about the diabetic foot is undertaken by diabetes podiatrists –
possibly in a bid to extend their charismatic authority to this hitherto apparently
resistant group. When exposed to the activities of diabetes podiatrists, the GPs
reaction is often one of shock:
“I think there’s a huge amount of ignorance and certainly in primary care,
I’ve seen GPs their, their gobs dropping when I show them some of the patients that we manage. And you can see them thinking bloody hell, you
know, you’re looking round, you go right [claps hands together] this patient arrives in your practice, what are you gonna [sic] do with it? You can see
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them thinking, don’t look at me, don’t look at me, don’t ask me that question [says own name], I am not interested in answering it, you know you can see
them all doing this dead bunny expression.” [SS 579-585]
In developing diabetes podiatry in primary care charismatic qualities (such as
tenacity) and charismatic authority in the form of professional reputation were
highlighted:
“I guess the way people have developed career pathways is to latch on to a
[pause], generally it has been a hospital that has a foot clinic and trying to get in there. Or to develop a service structure within primary care, for
example in Salford, Tameside you’ve got the Martin Foxes of this world and so and so forth who’ve developed a primary care pathway, em [sic] and if
you ask Martin, it’s tenacity again and working in a secondary care centre, getting known as a bit of an expert in there and then working in primary care
and developing care pathways and things within, within that.” [CG 368-374]
The devolution of diabetic foot care from secondary to primary centres is viewed as
a worrying development by some diabetes podiatrists because it represents a
possible loss or dilution of medical patronage:
“…with the devolvement of that to sec [breaks off] to primary care unless you have GP that are a real champion in the diabetic foot I can see that bit
just going [blows large raspberry]. And maybe a few odd people who are extremely outspoken, they may be well trained, they may not setting
themselves up as the king or queen of the diabetic foot, I don’t mean that but you know what I mean, there could be real champions. Em [sic] so I have a
few – I’m getting old [smiling] em [sic] I have a few concerns em [sic] now if the teams go out then fine and this is where the evolution of healthcare is
quite interesting and how it evolves and em [sic] and I think part of the influencing factors are what happens to amputation rates when services are
devolved from these centres of excellence in inverted commas, em [sic] into GP practices. Cos [sic] I’ve got a horrible feeling amputation rates are
gonna [sic] rise and admission rates are gonna [sic] rise, which will be sad.” [CG 784-795]
4.6 The Influence of Charisma
Charismatic qualities appear to be important and influential at all stages and in all
aspects of diabetes podiatry; from entry into diabetes podiatry to influencing the
level of clinical activity, through the impact on interaction with other professions, to
the formulation of strategy at local and national levels.
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4.6.1 Charismatic Potential and Entry into Diabetes Podiatry
Faculty of Management respondents highlighted key personal qualities which they
considered to be essential for a specialist:
“If we’re looking at the role, I mean the role that we need and it comes into
something that’s the terminology, the role is very much about the, the, the way in which people will be working, [clears throat], not just their clinical
knowledge and skills it, it, what is essential, critically essential is their ability to work in a team, to be able to lead er [sic] the team, to be able to integrate
and work with consultants and GPs and a whole range of other people, in a partnership way, that’s fundamental, the, the, the key skills and knowledge
em [sic] er [sic], they’re more than just a bonus but, but, but without the other factors somebody wouldn’t be a specialist.” [Faculty of Management
53-61]
Some Faculty of Management respondents incorporate assessment of key personal
qualities into the interview process for potential diabetes specialist podiatrists:
“ … last time we interviewed the, the presentation was actually as a podiatrist presenting to a GP practice er [sic] you know what the diabetic
foot clinic was and that side of it to make sure they had that, those skills because they’re quite important …” [Faculty of Management 887-890]
Indeed in appointing diabetes podiatrists, some Faculty of Management respondents
stressed their evaluation of charismatic potential, the type of person, the value of
motivation, and personal qualities; prioritising these facets over clinical skills –
which they considered could be learned later:
7: “Then you might get someone who’s coming along who’s very sort of
motivated, em [sic] hasn’t had the necessary experience but you think you’ve got the potential to take it forward em [sic]
1: Mmm [nodding] 7: just from how they come across from their presentation and their interview
and er [sic] you think oh yeah this person would, would in the organisation would move up erm [sic] quite quickly but it would be nice to er [sic]
develop them and support them 1: And the consultant, this is a medical team, where I work certainly have said
you know we just need to have the right type of person you know we can develop the skills you know in them, it’s more about the, you know the
personality and the person and er [sic] than the skills cos [sic] a lot of that stuff can be taught
7: Mmm [nods] 1: but the empathy you, is, is you know the ability to enable and empower erm
[sic] patients is, is, is such a key result area that, that actually some of the other clinical skills can become you know less important because we don’t
have to, we have to be realistic about what a, what it is we are able to influence as clinicians.
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8: It’s really all around about being a team player isn’t it. Just to work in a multi-disciplinary team and you can’t actually teach, you can mould people
but you can’t if they haven’t got those core team player type skills, that work. [pause]” [Faculty of Management 917-939]
The Skills for Health participant also acknowledged that personal qualities are an
important aspect of specialisation in diabetes podiatry and that education for role is
not the only consideration:
“I mean I’ve worked in a diabetic clinic and you need really to be erm [sic] dedicated, I think, to the role to do it and to take it further. I mean it’s not
everybody’s cup of tea, when you see some of the wounds and things you have to manage. Erm [sic] and therefore I suppose to a certain extent there
is, there is a certain degree of calling to it, beyond simply the education.” [BL 609-614]
4.6.2 Influence of Charisma on the level of clinical practice
Clinician respondents highlighted the importance of autonomy and confidence in
enabling them to practice effectively:
“ … but it is quite often that er [sic] we’re the first ones that see these people and you know check that they’ve got the right foot-wear, that their HBA1c s
what they are and you know we just coordinate everything really and I think that’s a big role that I’ve done when I’ve been doing DFCs [diabetic foot
clinics] and important to that, you know having the autonomy to do that and em [sic] and the confidence to do it …” [Expert Reference Group 1010-
1014]
Empathy and insight were also highlighted:
“I used to be quite intimidated or challenged by a difficult patient, now I love it, cos [sic] I think you know when you’re obviously annoyed because
someone’s done something to you and you, it just shows the different perspectives that when you approach a patient, walking in their shoes, rarely
do they stay angry and cross with you and where they doing that, start to work with you, cos [sic] all they’re looking for is someone to be an advocate,
and these are really poorly patients, if you think 50% of them are dead within five years of a foot ulcer.” [SS 206-212]
Development of empathy may be linked to the technique of Motivational
Interviewing, a tool which many diabetes podiatrists employ. Motivational
Interviewing is a strategy in which the clinician takes the patient’s perspective and
works with the patient to identify strategies to improve health outcomes (Rollnick et
al 2008). Concordance is said to be achieved through avoidance of conflict with, or
negative responses from the patient. By focussing on the patient’s perspective,
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insightful and empathic care planning is the focus of motivational interviewing
(Rollnick et al 2008).
In the absence of any formal, identified route to specialty in diabetes podiatry and
faced with financial and logistical difficulties in accessing courses, the personal
qualities of practitioners have been repeatedly highlighted in achieving professional
development. In describing these personal qualities, participants used emotive
language – tenacity, desire, drive, persistence:
“ …it’s a very difficult situation because there’s, as I talked about earlier we
haven’t, there isn’t that formal route through yet, em [sic] but some people through their own finances, through a helpful physician, have gone on
various courses, have taken themselves off to Kings, and to the Royal Infirmary at Edinburgh, or to the Manchester Royal em [sic] to gain some
courses, they’ve gone off to the States themselves, em [sic] it, it’s terrible that, that it’s that, they’ve hardly been enabled to do it, but those people who
have that sort of persistence and, and desire to gain these skills …” [JH 480-487]
4.6.3 Influence of Charisma on Interaction with Other Professionals
Communication skills, confidence and the ability to challenge the practice of others
were themes repeated many times in the accounts of all informants with the
exception of the Skills for Health respondent:
“Good communication cos [sic] unless you can communicate with other professionals, be it, be they above you because they are you know a medic,
or you know a consultant or somebody like that, or be they below you erm [sic], unless you can converse with those people you will lose a lot of your
potential benefits of being, of working in a multi-disciplinary team. So if you’re a lone worker then forget it, it’s not the type of job, so you’ve got to
be able to communicate. And there’ll always be challenges to your communication skills and there will always be challenges to that, either on a
personal note or on a general note, but I think you need to be able to communicate.” [MP 509-516]
But if you talk to any multi-disciplinary team, they, they view the podiatrist now as the key member of that team to bring things together, because they’re
engaging with the patient face-to-face and they can be crucial in that making the links, so having the communication skills and the, and the confidence to
go and talk to em [sic] other health care professionals is key. [Faculty of Management 347-351]
Within the context of communication, the ability to justify specific approaches and
requests was also highlighted:
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“… you know the consultant radiologists, if I ‘phone them up and say I’ve got an urgent patient, er [sic] need an MR scan they’ll usually get them done
within a couple of days. And that’s because I’ll ‘phone them up and tell them what the problem is, em [sic] rather than just sending a card willy-nilly
and just waiting for them to see it and decide what they need to do, so you know and he’ll challenge me and say, you know you, you, what you’re
hoping to find out, what information do you need, and you know he can assess that, if I ‘phone up and say I really need to know the extent of the
osteo-myelitis cos [sic] I’m taking them to theatre, it would give me a good guide to, to advise the patient of what the potential successes are…” [MP
247-254]
4.6.4 Networking
Networking was viewed by the diabetes podiatrist respondents as more than a
process of marketing their skills and services or educating other practitioners, some
exhibited an almost evangelical drive to attract, enthuse and involve as many
healthcare workers as possible:
“… you’ve got to be an octopus, you’ve got to be grabbing out in all directions and, and bringing on board everyone you can …” [SS 275-277]
Building and maintaining links was seen as they key to ensuring smooth referrals for
patients:
“ … as I said here, we, we’ve got an arrangement because we’ve developed
such links locally with the GPs cos [sic] I’ve done lots and lots of GP training, I’ve done lots of nurse training and things within the community,
and because this clinic has, is held in such high esteem, em [sic] anybody can refer in as long as the GP, cos [sic] the GPs say ooh yeah fine pshhh
[sic], send her in, send them up to Colin and the team, great cos [sic] we don’t want them.” [CG 688-693]
“… we have links they [vascular surgeons] come over and do clinics twice a
week, so we have links with them er [sic] and again we link with them so if their diabetic surgery that they’re needing, if their circulation is poor, then
we make a balanced judgement as to whether to go ahead with the surgery or get, if we’ve got time on our side get bypass done, then do the surgery. So
it all varies, so there’s a good link, working links…” [MP 24-28]
…and as a means of ensuring that the diabetes podiatrist did not work in isolation,
thus reducing potential liability:
“…network like a drunken spider with everyone around you to make sure
that everyone’s on board and that you’re not working in isolation. Because you know when the big, when the big bad barrister knocks on the door if
you’ve worked in isolation you haven’t got, excuse the pun, but you haven’t got a leg to stand on, really haven’t got a leg to stand on.” [SS 653-657]
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4.7 Charismatic Authority and Medical Patronage; Tensions, Limitations and
Constraints
Diabetologists recognise the potential for conflict with the charismatic leaders in
diabetes podiatry:
“… theoretically I’m the consultant on the list of the, and so I’m er [sic],
I’m, I’m responsible. I mean that is an issue with podiatr [breaks off] that is sort of an issue, because I think some podiatrists will feel uncomfortable with
that and would want to be sort of dominant with their name. [IM 223-226]
While based on the links established between podiatrists and diabetologists, the
podiatrist MP perceives a diminution in medical “ownership” of patients:
“You know and that’s the sort of link, you know that I think doesn’t happen
overnight it, that’s something that you build up and they know where you’re at, they know what you can do, but no one’s saying it’s my patient, the whole
idea that it’s my patient and I’ve got the overall say, hopefully in many cases has gone now and people are working far more with the sort of team
knowledge behind them.” [MP 218-222]
…IM, a diabetologist perceives the potential for podiatrists to challenge medical
ownership of patients:
“…our podiatrists could get [pause] stroppy let’s say, you know all, all the patients, essentially are under my name and you know, some stroppy
podiatrist might say “ahh [sic], I’m doing all this work, you know I ought to have my name on these people” [IM 518-520]
Given that charismatic leaders in diabetes podiatry now view challenging medical
practice as part of their remit (see section 4.3.2) two key factors appear to prevent
them from mounting a jurisdictional claim over the treatment of diabetic foot
disease; the ability of medical doctors to contain the podiatrists’ charismatic
authority and the podiatrists’ continuing need for a powerful sponsoring elite.
4.7.1 Containing charismatic authority
Two mechanisms which allow medical doctors to contain and constrain the diabetes
podiatrists are the podiatrists’ lack of formal admission rights and their status as
supplementary prescribers.
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4.7.1.1 Admission Rights
The inability of diabetes podiatrists to admit patients ensures their continued
dependence upon medical colleagues:
“At the moment, I don’t think they’d have the sort of, the political power to
arrange for the admissions. Which, which might get very frustrating.” [IM 187-189]
“…you can’t do it in isolation, you’ve gotta [sic] work with a team. You’ve
gotta [sic] be able to admit patients to, to em [sic] the ward if necessary.” [JB 350-352]
Though in extremis community based diabetes podiatrists have found ways to
circumvent this:
“a few weeks ago when I happened to be doing a home visit to see one of my patients … she happened to look really worried, I said you know, what’s
wrong, and she said oh it’s my son, he’s come to stay for the week and he’s not very well, he’s a diabetic and he’s woken up this morning saying his
toe’s gone black, could you have a look at it. And so I thought well maybe I would do expecting it to just be a sub-ungual haematoma or a bruise or
something and his whole foot was wet gangrene er [sic] he was systemically very unwell and he was a very ill man. And obviously I got him admitted
straight away, the GP practice had been called er [sic] but that’s where break-down in communication can occur, they said yes the GP will come out
maybe tomorrow and see you and that guy wouldn’t have survived the day he was so systemically unwell erm [sic] you know he, I got it coordinated and
the paramedics came, but I was actually quite surprised er [sic] at having to educate the paramedic, I would have thought that they must have had this
sort of experience before. But you don’t really need to have too much experience to know that that is pretty wrong, you need to get to hospital
pretty quickly em [sic] he said well what do you think I should do, I told him and I said well before I tell you what would you have done if I wasn’t here,
and he said oh I would have waited for the GP to come, which was a little bit sort of alarming. And so I took the opportunity to sort of educate him and
the guy got to hospital and they reckon that he got there just in the nick of time er [sic] he was very poorly well into septicaemia erm [sic] so you know,
I wasn’t really expecting to have to educate em [sic] paramedics but you know, we shouldn’t underestimate how much knowledge we do have
2: Mmm [nodding] 3: and the quick decisions we have to make at times. It’s very easy to pooh,
pooh what we do, its only feet, nothing can go wrong with the feet and people sort of laugh at some of the things we have, but we can make some er [sic]
very important decisions at times and yeah education of other professions is important as well.
8: Did they save his leg? 3: No it was quite bizarre cos [sic] I’d only rung up the next day or two days
later to see how he was and I’ve never heard somebody so pleased about somebody that’s had an amputation. She was ecstatic that he had an
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amputation, but she recognised how serious it was and that he, if he hadn’t
have gone then to hospital he would have died, they said he was into er [sic] septicaemia and he had horrendous problems but they managed to save him,
but obviously you just take one look at it and you knew it was a BKA [below knee amputation] and em [sic] you know [tails off]” [Expert Reference
Group 491-523]
Based upon the re-proven abilities of the practitioners involved (a necessity of
maintaining their charismatic authority) an approximation to admission rights for
one group of diabetes podiatrists had been achieved through the negotiations of one
diabetologist:
“I negotiated direct referral rights to our emergency medical unit for the podiatrists … they can ring our assessment unit, our medical assessment unit
directly and get, and get them admitted and one of the swinging factors was I told them the quality of the referrals you’ll get from those podiatrists will
exceed most, most GP referrals.”[AT 480-487]
This arrangement is though an unofficial one, relying upon goodwill and remaining
within the “gift” of the medical doctors involved.
4.7.1.2 Supplementary Prescribing
The diabetes podiatrists’ status as supplementary prescribers; based on patient group
directives and within the boundaries of formalised antibiotic protocols permits them
a form of prescribing which remains under medical control:
“[one of the competencies is about] depending on an enabling physicians in
the hospital setting, more so in a primary care setting about changing prescription antibiotics.” [JH 258-260]
Diabetologists acknowledge their role in allowing the diabetes podiatrist to
undertake supplementary prescribing:
“…sounds slightly pretentious but I, I think of one’s, my role as er [sic], has allowed the roles of podiatry to flourish. Er [sic] because they can proceed
with all their er [sic] techniques, procedures, assessments emm [sic] and antibiotic cover er [sic] without having to go running here, running there or
being rebutted here and rebutted there and taking away all that hassle. [IM 213-218]
…which they see as a form of boundary blurring or sharing of roles, but importantly
one which still requires their endorsement:
“And there’s the, and there’s the interchange of, of roles with, with us as medics, because now we’re working with podiatrists who are em [sic]
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prescribers. So em [sic] yes, I’m backing them up but they’re actually even taking that role as well.” [AT 61-65]
The diabetes podiatrists’ lack of independent prescriber status can make working in
the community more difficult:
No podiatrists can’t be independent prescribers yet … as yet no it has to be
supplementary prescribing, which means that I have to agree the care plan and here I support that em [sic] but in the community erm [sic] it’s the GP
who has to be the independent prescriber, so they have to agree care plans and that’s, that’s difficult then, em [sic] because they’re not always
geographically in the same place and so that, trying to get support and the care plan signed up is more difficult for the podiatrist working in the
community.” [AT 92-104]
…about which several diabetes podiatrists expressed frustration:
“Give us advanced prescribing rights and it would be a whole lot better if we could go direct to our antibiotic use - that would make a big difference to
us.” [Expert Reference Group 1068-1069]
“…independent prescribing is in a bit of a mess though at the moment
because, I’m certainly involved in a little battle at the moment where they’re pushing like mad for us to become supplementary prescribes in the
community and the models that they work is not fit for purpose. It works in the hospital, I mean I prescribe in the hospital but in community legally your
independent prescriber has to see a patient, well by the time your GP’s come out, seen the patient, seen the patient, signed your CMP, he’ll be thinking
what, well what’s the point here, what’s going on here…” [SS 369-375]
“…woe betide us, sue the arse off us for getting it wrong, but don’t hold us
back from doing it [independent prescribing]. Because the way they’re doing it at the moment, people are trying to find short-cuts for supplementary
prescribing, and what’s gonna [sic] happen is that they’re gonna [sic] open themselves up to litigation, you’re gonna [sic] get people getting blanket
signed care management plans by medics that haven’t seen the patient, then the Barrister will get it and say to the medic- did you see the patient on that
day- and no [shakes head as if medic is saying “no”], and the podiatrist will get it in the neck because that is illegal, inappropriate prescribing” [SS 565-
571]
4.7.2 Loss of Medical Patronage
Podiatrists employed within the multidisciplinary diabetic foot team under Service-
Level-Agreements are vulnerable. Termination of the Service-Level-Agreement
results in their return to the employer (usually the Primary Care Trust):
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“… I worked with a group of podiatrists employed by the community trust,
by the PCT, which whom I’d worked some of them for 20 years, em [sic] and at least 10 years and we had huge understanding and they were all specialist
podiatrists. As of October 2009 the acute trust decided it would employ its own podiatrists and served, 6 months earlier had served notice on the em
[sic] SLA, the Service Level Agreement.” [AT 121-127]
This effectively ends the diabetes podiatrists’ practice within the hospital based
multidisciplinary diabetic foot team, removing them from the support and patronage
of the medical diabetologist. In this situation, their claim to specialist status will rest
solely on their charismatic authority, unless they can secure the support of a medical
doctor in the community.
4.8 Sustainability of diabetes podiatry
The absence of any agreed and formalised educational preparation or defined career
pathway means that diabetes podiatry lacks educational credentialing. The specialty
is only loosely underpinned by small sections of health policy, embedded within
National Service Frameworks and clinical guidelines. Thus claims to legitimate
specialist status have relied upon medical patronage and the charismatic authority of
its practitioners.
4.8.1 Lack of Faculty Status
The podiatrists’ professional body, the Society of Chiropodists and Podiatrists while
granting faculty status to podiatric surgeons and podiatry managers, has so far
resisted fragmenting the large faculty of podiatric medicine and general practice (of
which the diabetes podiatrists are a part) into smaller, specialised faculties:
“…so if you’re a surgeon – you’re a specialist, you’ve got your own faculty. If you’re a manager – you’re a specialist, you’ve got your own faculty. If
you’re a generalist you’ve got your own faculty but there’s eight and a half thousand of you in there and the tension in the Society is – does each
specialism have its own faculty?[laughs] em [sic] and my answer is absolutely not otherwise you know … once you begin to say no, well diabetes
is a faculty, rheumatology is a faculty and so on, then you, you get in danger of just having pockets of people who never talk to each other.” [JB 119-128]
One of the main reasons for not establishing more faculties is financial:
“…every time you spawn a different em [sic] group of people, they need supporting. And they almost need an officer of their own, cos [sic] once you
start that you, you have to invest more money and I don’t think the Society at the moment has got that money to pay for it …” [JB 156-159]
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Practitioner numbers, expertise and evidence base were considered to be the pre-
requisites for Society of Chiropodists and Podiatrists faculty status:
“But I don’t think at the moment we’ve got critical mass em [sic] of people
or expertise that justifies a faculty. So and when I say expertise I would think have you got the research base, have you got a critical mass of people,
have you go the clinical evidence that suggests that this is really a specialism on its own?” [JB 171-175]
4.8.2 Fragility of Charismatic Authority
While those podiatrists who seek the continued development of diabetes podiatry
still display and use charismatic authority, there is recognition of the fragility of this
form of authority:
“I’m involved in pushing the national profile of podiatry which I’m really
passionate about em [sic] I think there’s too many of us that are a bit shy in podiatry at coming forward professionally and we’ve got so much to offer,
we’ve got a long way to go but we, we have, we made a difference in diabetes.” [SS 189-193]
“… there is not an Ali Foster in every part of the UK. You know there’s not a Louise Stuart, there’s not a Neil Baker, there’s not an Alistair McInnes,
there’s you know I’m sure you could name the key folks in the country, but em [sic] [sighs] you’re not gonna [sic] have those, but there should be the
facility and this is what I guess concerns me is that at the moment its only by the tenacity of certain individuals to make sure they get up there, what I’d
like to see happen within our profession is a vehicle to allow people to progress there, because when certain folk retire, who’s gonna [sic] take their
place, who, who’s actually gonna [sic] be the ambassador for podiatrists in the diabetic foot?” [CG765-773]
4.8.3 Routinisation
Routinisation – the replacement of charismatic authority by a more stable form of
authority – is evident at many levels. At the direct patient-contact, micro level, the
transition from charismatic to rational-legal authority is accomplished via the use of
tools such as care pathways:
“… it’s so simple to put a care pathway and get it through the governance
structure, get it into the system, it’s so simple to get a care pathway through and then police it and then go out and promote it, sing it from the hilltops,
just go out to every group and say this is the care pathway, it’s not a painting, stick it up in your clinic, this means when you get a shitty horrible
patient with a gammy infected ulcer that you don’t know what to do with, you don’t know whether to get an ambulance or whatever, call us out, we’ll take
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it off you. And they’re like, whoa [sic] that’s, that’s fantastic. Such a simple
mechanism is effective, yeah, without a care pathway, you might have a passionate individual like you might have a Neil [Baker] or a Louise [Stuart]
or an Alistair [McInnes] or whatever, but if someone but if someone yeah, you refer to Alistair or Louise, yeah they’re good at it, what happens if I die,
what happens if I leave what happens there. You have to have a robust infrastructure of care that those patients can navigate through, cos [sic]
without that navigation system the patients get lost. They get lost, you can’t possibly speak to every single person and have them all on board, but with
your care pathway, we sing it and you actually make sure that every practice has it, the nurse has it they’ve all had training, they’ve all had e-mails on it
and then you give them updates.” [SS 489-513]
The influence of diabetes podiatrists over the care pathway is accepted and expected
by Managers:
“For me they work across and influence the whole pathway, from start to,
from start to finish … [Faculty of Management 285-286]
Specific reference to podiatry in the NICE guidelines for diabetes represents
evidence of macro-level routinisation which has been achieved:
“ …but the fact that the NICE guidelines mentioned the role of podiatry was people like Neil Baker and Louise Stuart who got into those committees to
influence the reports on podiatry, otherwise it would have been left off.” [JB 215-217]
At the strategic, macro level further routinisation is underway; as evidenced by the
creation of “National Minimum Skills Framework for Commissioning of Foot Care
Services for People with Diabetes”. Faced with what they perceive to be an
inadequate Diabetes Framework – newly created by Skills for Health, Foot in
Diabetes UK developed their own National Minimum Skills Framework:
“I don’t think it’s [the Skills for Health Diabetes Framework] much help to us. Em [sic] the whole reason why we did the Minimum Skills Framework
was because it was inadequate and I think it was a great shame that they spent so much time and effort, so much money into that …” [SS 673-676]
Montgomery (2003, p15) points out that such guidelines form what is known as
quasi-law and while not strictly legally binding may have some legal force, for in
practice they determine the way in which people should act:
“… because policy and practice now exists to say if you don’t have these
skills – the minimum skills framework and you can’t see this patient and access these individuals – then pass the patient on to someone who can.” [SS
428-430]
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The production of the National Minimum Skills Framework represents the
formulation of health policy at national level by Foot in Diabetes UK. This was
achieved via the use of inter-agency cooperation and endorsed by Diabetes UK, the
Association of British Clinical Diabetologists, The Primary Care Diabetes Society
and The Society of Chiropodists and Podiatrists.
“…you know the Minimum Skills Framework was a pain in the backside to get it through in a very short space of time, but collaboration is the key to the
game get everybody on board, you don’t want to really do anything in isolation. Create waves.” [SS 639-642]
Having established the National Minimum Skills Framework, Foot in Diabetes UK
is now turning attention to education and assessment of diabetes specialist
podiatrists:
“the future needs to have, like the podiatric surgeons, needs to have a definite exam system and structure, so that people are then at least
potentially entering these posts with a good knowledge and understanding and also a good knowledge that they can er [sic] relate and pass on to other
people.” [MP 284-287]
“…we’re developing a curriculum that’s gonna [sic] sit in tangent with, the
curriculum’s gonna [sic] sit in tangent with the National Minimum Skills Framework.” [SS 617-618]
Diabetologists recognise the need for specialist training and display a certain
frustration with the diabetes podiatrists’ lack of progress in this area:
“… I don’t think podiatry has got itself together basically… what needs to happen is podiatrists interested in the diabetic foot needs to, need to bring
themselves together, developing, develop the training programme. I mean I think that one of the sad things apart from a few podiatrists a lot of what has
happened is actually dependent on diabetologists, which you know is, we can’t argue, we’ve tried our best em [sic] but actually you need to do it
within your own organisation [tails off]” [OM 272-281]
Faced with frustrations in the development of a specialised diabetes podiatry
curriculum, diabetes podiatrists seek to formulate a national curriculum to be
endorsed by Diabetes UK rather than the Society of Chiropodists and Podiatrists:
“Lack of vision, professional vision. Em [sic] this, this is what I’ve got quite cross with, with the Faculty of Medicine, because there just seemed to be a
real lack of grasp of opportunities that we have.” [CG 805-807]
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“… there needs to be a national curriculum, which, which we’re on with at
the moment, we’re getting Diabetes UK to em [sic] allow us, allow me to lead a task and finish group to write that.” [SS 397-399]
In this way those diabetes podiatrists who see themselves as leaders are utilising a
powerful sponsoring elite to support their formulation of health policy and endorse
their educational output. Such educational output would in turn represent the
educational input for future diabetes podiatrists. If successful these developments
would represent significant further routinisation at a strategic, macro level.
4.9 The Importance of Medical Patronage
Within the data there is repeated emphasis upon the importance of medical
patronage in secondary care, both historically and in contemporary settings. The
potential loss or diminution of such patronage through a move from secondary care
settings into primary care is a cause for concern amongst diabetes podiatrists.
Medicine as a profession is still able to exert a controlling influence over the
healthcare sector (see section 1.8 Medical dominance). Within the secondary care
setting, diabetes podiatrists have detailed how they engaged with medical doctors,
gaining the support of diabetologists and then the wider medical team.
Diabetologists are considered to be the leaders of diabetes teams and for diabetes
podiatrists they act as quasi-employers. In this way the diabetologists provide the
link to Freidson’s institution for the diabetes podiatrists. Freidson (1988) does not
consider knowledge itself to be a system of domination, but rather that the
professions, as agents (creators and users) of knowledge are provided with
opportunities to exercise power via the institutions which sustain them. Medical
diabetology appears to be the institution which sustains diabetes podiatry, indeed
within the accounts of some respondents medicine (in secondary care) is identified
as the organisation which allowed, encouraged and enabled the development of
diabetes podiatry and which is committed to its further development. They contrast
this sharply with the role of their professional body, which they consider to have
been far from enabling and supportive. The diabetes podiatrists also highlight the
difference of their relationship with doctors in primary care, citing GP’s lack of
awareness of their skills, and potential utility and pointing to communication
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difficulties. Thus diabetologists as leaders of the hospital diabetes teams provide the
situation and opportunity - the institution - where diabetes podiatrists can exert a
degree of power and from which they derive enhanced status. Potential loss or
diminution of such legitimating support makes the diabetes podiatrists’ concerns
over a move into primary care understandable.
4.10 Why has Charisma Been Such an Important Influence?
The first “iconic” diabetes podiatrists established an area of specialist practice based
on knowledge, clinical skills and working practices which differed from that of other
podiatrists. Their authority was charismatic. Weber (1968) identifies charismatic
authority as power legitimised on the basis of exceptional personal qualities or the
development of extraordinary insight. Indeed, the accounts of almost all
respondents are replete with references to the personal qualities, charisma,
innovation and insight of these early icons. Another feature of charismatic authority
is the ability to inspire followers – this phenomenon is evident in the way in which
dissemination of ideas, treatment modalities and models of practice was achieved
via the use of publications and presentations; effectively launching a formalised
specialty within podiatry based on charismatic authority. Due to the requirement for
diabetes podiatrists not to work in isolation the personal qualities and charisma of
the individual podiatrists has represented a key factor in the further, on-going
development of this area of specialist practice. Indeed charismatic authority appears
to have been the most significant influence in the formation of specialised diabetes
podiatry for it was the means by which medical patronage was secured. This
patronage and support of key medical individuals has been essential at every stage in
the development of diabetes podiatry and continues to exert a major influence over
the specialty. Such phenomena were also considered by Weber (1968) who
highlighted that charismatic authority almost always evolves in the context of
boundaries set by traditional or rational-legal authority. Medical doctors have made
use of the charismatic authority of podiatrists working within what they consider to
be “their” teams; podiatrists have engaged in wide ranging educational and
marketing activities which reinforce the status and importance of the diabetic foot
team. While motivation for undertaking such activities may be linked to the
professional project of the diabetes podiatrists, their inextricable tie to the
multidisciplinary team means that the team is also the beneficiary of their
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promotional activities. Though diabetologists recognise the potential for conflict
with these charismatic individuals, it seems that while the authority of the podiatrists
remains a containable and useful phenomenon medical support is likely to continue.
This ability to constrain their charismatic authority, coupled with the podiatrists’
need for a powerful sponsoring elite may be what prevents diabetes podiatrists from
challenging medical leadership of diabetic foot teams and mounting a jurisdictional
claim over the treatment of diabetic foot disease. Thus medical dominance which is
entrenched in the structure of the NHS acts as both an enabling and constraining
force for diabetes podiatry.
Recognition of the fragility of their charismatic form of authority has led key
individuals – notably Foot in Diabetes UK executive members – to seek more stable
and formalised legitimation for diabetes podiatry. In the process which Weber calls
“routinisation” charismatic authority is replaced by a bureaucracy controlled by a
rationally established authority or by a combination of traditional and bureaucratic
authority. This routinisation is evident at many levels from the use of local health
policy in the form of care pathways by individual podiatrists; to the production of
national policy by Foot in Diabetes UK. These pathways and policies not only
represent what Montgomery (2003) calls “quasi-law” which will impact on the
clinical activities and caseload of podiatrists, they also form further key legitimising
strategies for diabetes podiatry via the establishment of rational-legal authority.
Care pathways form a particularly ingenious approach; while to a certain extent they
do codify knowledge, more importantly they have been used to shape and direct the
clinical activity and referral patterns of other health professionals. In this way care
pathways have been used to strengthen the jurisdictional claims of diabetes
podiatrists over the control of managing diabetic foot disease.
Respondents’ emphasis on the importance of key diabetologists led the researcher to
consider whether the diabetologists were in fact the charismatic leaders and the
diabetes podiatrists their disciples. Extensive reflection on the nature of charismatic
authority, how it manifests and its effects has led the researcher to conclude that
while the diabetologists may indeed be charismatic individuals and may use
charisma to advance their claims and raise their profiles; diabetologists’ roles, titles
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and positions are legitimated by rational-legal authority. In contrast to this the
diabetes podiatrists, lacking educational credentialing and formal career pathways
rely upon a blend of charismatic authority and medical patronage to legitimate their
roles, titles and positions. Charismatic authority has been extensively utilised by the
diabetes podiatrists to develop, disseminate and defend an area of specialised
practice within podiatry. The context in which change over time and contemporary
developments have taken place has been shaped by national and local health policy,
the influence of medical dominance, the negotiations and the professional project of
podiatrists. However charismatic authority has proved to have continuing relevance
in shaping the on-going development of the specialty at micro and macro levels;
routinisation strategies represent contemporary attempts to secure a legitimate long-
term future for diabetes podiatry as an identified specialty.
150
151
5.0 Title
The following chapter explores issues surrounding specialist titles, their significance
and implications.
5.1 The Variety of Titles in Diabetes Podiatry
While much of the advertising for posts assigns the title “Diabetes Specialist
Podiatrist” to podiatrists specialising in diabetes, during data gathering it became
apparent that nomenclature associated with specialised podiatry practice in diabetes
is highly variable:
Well they’re still not called Diabetes Specialist posts are they? Sometimes
they’re diabetes clinical lead, there’s no consensus what, what they’re actually called is there? [SS 437-439]
Because the skill-set remains undefined, no official, formal title has been assigned to
podiatrists specialising in diabetes:
“And we haven’t actually defined and said what are the skills that would be needed to become a specialist podiatrist tut [sic], so, so these are still
unofficial titles, but I would still tend to use those and when introducing them to, introducing people em [sic], to colleagues or to patients, I would say
that’s specialist podiatrist…” [AT 553-558]
Indeed, clinician-participants’ titles within this research included:
Podiatry Pathway Lead for the at-risk foot Senior Podiatrist
Lead Podiatrist Chief Podiatrist
Specialist Lead Podiatrist Wound and Diabetes Specialist Podiatrist
Lead Podiatrist in Diabetes Podiatrist
Podiatry Clinical Service Manager [Also working part-time in diabetes podiatry].
Diabetes Specialist Podiatrist Consultant Podiatrist – Diabetes
Diabetes Specialist and Research Podiatrist
This plethora of titles associated with practice in diabetes podiatry was singled out
as a cause of confusion:
2: “I think that the term diabetes lead confuses it as well.
7: Yeah 2: You know are they the expert, are they co-ordinating it or what’s their role
within this as well.” [Faculty of Management 86-89]
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Agenda for Change appears to have compounded the confused nomenclature:
1: “There is a, there’s a, there’s a, there’s an advanced, there’s a specialist
profile? Which I don’t think necessarily copes at this level, higher than that is advanced practitioner
4: practitioner [nods] 1: and then there’s a principal
4: Mmm [nods] 8: It’s not called advanced practitioner isn’t it, what’s it called highly
specialised I think 1: I think that’s what it started off being, but it’s, isn’t it spec [breaks off] I’ve a
feeling its 8: Band isn’t it band er it’s highly specialised and I think it’s band 7 isn’t it
3: Band 7, I’m not sure what it’s called 8: and then they’ve raised podiatry principle 8a wasn’t it and, but that had a lot
of things in it. I don’t know it’s interesting to see what everyone’s em [sic] we’ve probably all been doing the same things at different bands.” [Faculty
of Management 949-963]
Indeed on occasions titles appear to have been assigned without consideration of
meaning, purely in a bid to speak the language of modernisation embodied in
Agenda for Change:
7: “… at the conference we were just at, somebody came on who was giving a
talk and they were an expert podiatrist – and she said look don’t get the wrong idea here I’m not saying I am an expert, its Agenda for Change I have
to, I have to put this down …” [Expert Reference Group 91-93]
9: “It’s interesting in Scotland they’ve, they’ve added Highly Specialised
Podiatrist Many: Mmm [expression of interest]
9: as their title so I was talking to a Scottish colleague, so Highly Specialised, but when you ask them what does highly mean, it’s just a title to, to meet the
needs of Agenda for Change” [Expert Reference Group 77-80]
5.2 “Specialist” Titles
Within the confused nomenclature it is the term “specialist” which is most
controversial for practitioners. Specialist titles are the subject of on-going reflection
and debate. However while practitioners frequently point to their discomfort at
being assigned “specialist” titles, there is no move away from them within the
profession.
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5.2.1 Origins and Meanings of Specialist Titles in Diabetes Podiatry
Respondents considered that the role for podiatrists in diabetes pre-dates any formal
title:
“I think the role came in before the title came in.” [Faculty of Management
338]
Early practitioners may have been regarded as specialists and indeed styled
themselves as such; initially this diabetes focus was expressed in terms of having a
special interest:
“Er [sic] there have been people who have been regarded as specialists in
diabetes and have penned themselves that as opposed to a formal em [sic] route, erm [sic] I know in the early days those who had an interest would
call themselves diabetes em [sic] podiatrists or specialist interest in diabetes as opposed to specialist, so with specialist interest to begin with …” [JH
676-680]
“Specialist” began to be used formally in titles approximately 15 years ago:
“there are a couple of us who I, I guess were designated as specialists em [sic] about 15 years ago, 10, 15 years ago. So I’m thinking of folks like Ali
Foster, myself in Southampton, I was actually recruited to em [sic] at my interview I was told that it was one of the first Diabetes Specialist em [sic] in
fact let me tell you about – I got my Chief III grade as a Diabetes Specialist hmm, mm I think it would be 15 years ago I guess and that was seen as quite
new, quite unusual.” [CG 628-638]
A recurring theme throughout this data, JH once again highlighted the impact of key
individuals in the development of diabetes podiatry as a specialised area:
“… it was just seen as part of the duties as opposed to a specialist requirement, so that’s just really evolved from the pioneers of Ali Fosters
and Louise Stuarts and Neil Baker and em [sic] tut [sighs] a whole, a whole number of key personnel along the way.” [JH 684-687]
The debate over the meaning of “specialist”, how specialist titles are attained,
assigned and justified continues:
7: “There’s a debate over whether you call them specialists and what specialist means.
1: Yeah cos [sic] that’s a big debate, what’s, what, what do you link to, why do you call someone a specialist and not somebody else, just a podiatrist, em
[sic] and cos [sic] there’s all these, there’s “diabetes specialist nurse” and now there’s “diabetes specialist podiatrist” being bandied around, but how
do they prove they’re a specialist when people in diabetes, they say “I’m an advanced practitioner”, “I’m a podiatrist” or “I’m a diabetes podiatrist”,
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“I’m a diabetes specialist podiatrist”, so if you see that on their application
form in their role, what does that actually mean?” [Faculty of Management 66-77]
This confused situation has not changed over time:
“… [historically] a lot of people were concerned about levels and quality
and what made somebody a - and it still is the question today, what makes a specialist podiatrist.” [JH 122-135]
Once again Agenda for Change appears to have increased confusion, particularly in
the assignment of “specialist” titles to practitioners who do not undertake specialised
work:
3: “I think a lot of people would have preferred us to be called a Diabetes Specialist Lead, but because of the structure of Agenda for Change meant
that a specialist role was actually a grade 6, anybody above that on a 7 would be called advanced, so that’s lead to some confusion in terms of the
title we tend to use, so some of our junior colleagues that don’t do specialist work actually have the title specialist podiatrist.” [Expert Reference Group
55-59]
5.2.2 Why are Specialist Titles Problematic?
A possible explanation for the difficulties surrounding specialist titles was elicited
through use of Morse’s model of concept analysis. During the concept analysis
tensions between the everyday and scientific uses of “specialist” were made explicit
(section 1.6). It is perhaps these tensions and disparities manifest in the differing
meanings, values and expectations assigned that has led professionals to shy away
from the title “specialist” and instead adopt terminology such as “competence” and
“competences”:
7: “There is a lot of debate nationally what recognition because of looking from the Diabetic Foot Conference in Glasgow last month, it was this, this
debate came up about what people call themselves 1: Yep [nodding]
7: and, w, my, er [sic] a vascular surgeon from [name of trust] was on part of the panel and they were saying, everybody was saying what’s a specialist
and what should we call ourselves 1: Yeah
7: what grade, and he put his hand up and said why are you focussing on the word specialist, we had specialists in medicine 15 years ago and we shot
ourselves in the foot, I say I’m not a specialist in vascular surgery, I’m competent in what I do …” [Faculty of Management 789-1000]
155
9: I suppose the medical model has taken away from specialism now, they use “competence” cos [sic] you don’t go and see a specialist, cos [sic] that got,
so now they stand up and say well I’m competent, I can clearly demonstrate my competences. [Expert Reference Group 115-118]
Podiatrists were not necessarily comfortable at being assigned the title diabetes
specialist podiatrist:
“… I don’t honestly ever know if I, I sort of go along with that description in
so far as the things that I’ve been invited to, the things I’ve been asked to do and the things I have done along the way. So I sort of slightly squirm in my
chair at being described as that …” [JH 64-67]
Indeed some podiatrists displayed a clear dislike of the term “specialist”:
7: “… from the new entry graduates moving, who are coming up from band 5, 6 and then moving up into a specialist role isn’t it, or a, a competent role, let’s
get rid of that word specialist” [Faculty of Management 785-787]
Other podiatrists were accepting of the title “specialist”, though repeated changes in
their titles under Agenda for Change appeared to have been disorientating:
6: “I don’t mind specialist, I’m trying to think now whether I’m an advanced,
but my, my title’s changed so many times, that I think I might even be Advanced Specialist Podiatrist, now you say cos [sic] I think our job
description is advanced if you [interrupted] 3: If you’re a grade 7 you’d be advanced
6: it is advanced specialist yeah …” [Expert Reference Group 65-69]
5.3 The Effects of Titles
Titles and the sometimes subtle differences in title have significant effects.
Nomenclature can impact on access to services, clinical activities and roles and how
others perceive the title holder. Within the law, the adoption of specialist titles also
has significant ramifications.
5.3.1 The Effects on Clinical Activities and Access to Services
Alluding to the effects of title on access to services, BL questioned the way in which
the specialty had been framed:
“… do you necessarily want a specialist defined in, in the context of one condition or do you want the specialist defined in the context of treatment of
the similar types of conditions that manifest, the symptoms that manifest themselves from many conditions … “ [BL 309-310]
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Indeed, all participants agreed that title has an influence on access to services. SS
highlighted that while framing the specialty in terms of diabetes focuses attention on
diabetes it also restricts access to services, effectively penalising patients without
diabetes. She suggests that a “Consultant Podiatrist - High Risk” title and
incorporating diabetes into the National Service Framework for Long Term
Conditions would secure access to specialised podiatry services for non-diabetic
patients:
“I actually find my title very limiting, to be a Consultant Podiatrist/Diabetes
is very limiting, I’d far more like to be known as Consultant Podiatrist Diabetes, High Risk. Cos [sic] we shouldn’t be penalising patients because
they don’t have diabetes. If patients have a clinical need for good antibiosis, for good systemic, for systems of care, for complex co-morbidities to be
managed by best medical therapy, for offloading, for exercise, for smoking cessation, yeah I can appreciate we’ve only got so much money to go round
but I’m far more than I’m paid to be, high risk and not a diabetes specialist podiatrist. I think it’s good because it gives diabetes that agenda, there’s
that agenda of, and I think in fact eventually diabetes will become part of “long term chronic conditions”… Certainly from a patient point of view it
will mean that other patients get access to specialist services, cos [sic] at the moment they’re ring fenced for patients with diabetes as they are now. It’s a
rotten shame if they haven’t got diabetes and they’ve got some other high risk lower limb complications isn’t it? [Pause]” [SS 437-454]
8: It definitely does penalise patients if they haven’t got diabetes cos [sic] you are the, if you call yourself a diabetes podiatrist, you, you’ve then got that
let-out that you won’t see people that are high-risk that haven’t, you could in theory use that as a sort of get-out clause couldn’t you.
5: Or even if you don’t use that, that get-out clause other people will, you know so they [interrupted]
8: The system isn’t there. 5: Yeah, so they might have struc [breaks off] they might have access to very
good podiatry but if that patient then needs members of a multi-disciplinary team they’re just not going to get it.
7: I think that’s true. 5: Yeah. [Expert Reference Group 292-300]
A compelling example of the effects of titles on clinical activities and access to
services was provided by the “wound and diabetes specialist podiatrist”. The effect
of including a single extra word - “wound” within this practitioner’s title serves to
focus and restrict her activities to those involving wounds, effectively narrowing her
scope of practice by excluding pre-emptive and preventative work. However the
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impact on eligibility for high-risk podiatry services is to permit access for non-
diabetic patients:
“I would say like with us because we are not just diabetes, our, all our
clinics are wounds but actually diabetes is important but cos [sic] we’ve got wound in our title it sort of covers actually what we do and so it isn’t, its
rheumatoid, its people with neuropathy who aren’t diabetic, its em [sic] you know anything that walks in our clinic that needs to be debrided and
dressed.” [Expert Reference Group 60-63]
Organisational changes facilitated one diabetes podiatrist’s negotiations with the
newly in-house vascular surgeons. Effectively employing further medical
patronage, the podiatrist illustrated that by securing support of the vascular surgeons
she was able to mitigate the effect of her “diabetes” title and establish informal,
unwritten access to her clinic for non-diabetic patients suffering from peripheral
vascular disease:
“It’s something that’s really just happened by default because of cl, [breaks off] working relationships with diabetes and then you come across someone
with the same problems who hasn’t got the diabetes diagnosis erm [sic], you say well look I’ve got this person are you happy for them to be seen in this
centre and get the vascular surgeons involved, yeah that’s fine, cos [sic] at the end of the day we’re here to see people and patients and you know if in
the past if it needed the diabetes consultant to refer to vascular surgeons in a neighbouring hospital then that wasn’t possible erm [sic] unless they had
diabetes, but now because they are all on site it’s not an issue because the communication is there, but in an unwritten, non-formalised way.” [Expert
Reference Group 337-344]
5.3.2 Effects of Title on how the Title-Holder is Perceived
Titles are used to convey seniority and the hierarchical position of the title holder.
Once again the effect of title changes imparted or influenced by Agenda for Change
was criticised. Respondents pointed to the retention of older titles which are
technically no longer extant in a bid to express levels of seniority:
4: “Agenda for Change just sort of lumps it into bands whereas previously with the previous grading there was very much more of a stepping of
advancement within the profession which really is being wiped out with Agenda for Change, despite the varying titles that exist. Em [sic] so
although technically chief podiatrist doesn’t exist in Agenda for Change, it still, you know in the same way as the senior podiatrists, specialist lead
podiatrists, none of those per se are in Agenda for Change, but you’ve gotta [sic] have something that’s sort of signifies where you sit in the hierarchy I
think.” [Expert Reference Group 70-76]
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While, conversely other groups of podiatrists had elected to retain older titles in a
bid to reduce the possible divisive effects of hierarchical titles:
2: “I’m probably the only one who retains the title of purely senior podiatrist, but the circumstances of the area that I work in, there’s a very small number
of podiatrists and it was considered less divisive if I retained the same title as everybody else …” [Expert Reference Group 81-83]
The avoidance of “specialist” titles was justified by some Trusts so as not to imply
specialist qualifications and career structure were none exist:
1: “Our Trust’s decided not to use specialist at all in any of our titles throughout the whole of the, the em [sic] pay scale because of the pre-
conception that specialist means a specific career structure, a specific extra qualification and there isn’t that so they’ve decided that they wouldn’t use
specialist at all. So our diabetes team are advanced practitioners in diabetes, they’re not specialist podiatrists.” [Expert Reference Group 95-99]
For, beginning to hint at legal implications associated with “holding out”, Expert
Reference Group respondents highlighted the public perceptions of practitioners
with expert and specialist titles:
8: The public perceive specialist or expert as, as someone who is able to work at a much higher [interrupted]
6: Should be more qualified, have more qualifications 9: I would say it’s that sort of that expectation. [Expert Reference Group 112-
115]
5.3.3 The Legal Implications of Title
The Skills for Health respondent pointed to how the legal protection of title enjoyed
by podiatry effectively protected the use of any specialist podiatry titles:
“They [non-podiatrists] couldn’t call themselves podiatry specialists, because they couldn’t use the title podiatry.” [BL 482-483]
Some diabetes podiatrists have been the accused party in patients’ law suits. In
relation to this and echoing Montgomery (2003, p177) who highlights the different
standards of care considered acceptable for specialists as opposed to general
practitioners, CG speaks of the higher level of responsibility and accountability
inherent in specialist practice:
“… I’ve had two lawsuits against me... Em [sic] [sighs] it [title] has major, major em [sic] as a specialist you, you, and there again I, I think people like
the title em [sic] and like wearing the badge, but may not like some of the horrible things that come with it because responsibility lies with you as a
159
specialist, if you’re directing treatment, if you’re initiating treatment you’ve got to be responsible for that and you’ve got to be able to justify and that’s
why the research, critical appraisal, evidence based practice is so important and so you’ve gotta [sic] be aware that you’re likely to be sued during your
career – that goes with the job. And I have to say it is increasing in the diabetic foot and it will continue to increase.” [CG 605-617]
Specialist status was highlighted as increasing the clinician’s responsibility not just
to patients but also other clinicians:
“…people need to accept the responsibility they’ve got and it is different in the sense that you’re dealing with more complex patients and if you’re there
as a specialist then you’re also there as a resource to other staff and other, other clinicians …” [MP 118-121]
Montgomery (2003) points out that members of specialist units will be expected to
display greater skills than someone in an equivalent post in a general setting (p178) -
the standard of care following from the category of skills that the practitioner
professes and the position held by the professional (Montgomery 2003, p177). In
this way by including “specialist” within their title, by asserting specialty in the area
of diabetic foot disease, by accepting a post as a diabetes specialist podiatrist, or a
post within a specialist diabetes foot care team, the podiatrists’ standards of care and
level of expertise considered legally acceptable become higher than those expected
of a generalist or community podiatrist. Thus, under the law diabetes podiatrists can
be held to account for their specialist titles and posts. Where litigation should arise,
the standard of care against which their practice will be measured using the Bolam
test, is that of other practitioners skilled in the particular specialty (Montgomery
2003).
5.3.4 Effects of Title on Other Clinicians’ Perceptions
Clinician-participants considered that their titles were often poorly understood by
others working in healthcare:
“… people think ‘what the friggin [sic] hell’s a Consultant Podiatrist’ and I think well here I am and this is what I can do for you, and I am such a
fantastic tool in your tool-box in the community, use me.” [SS 81-83]
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One clinician-participant highlighted the hostility of some members of the medical
profession, who view the use of “consultant” titles by podiatrists as a mechanism to
“fool” patients:
“I’ve er [sic] had em [sic] eminent, I suppose in one sense orthopaedic
surgeons saying that er [sic] podiatrists just want to gain the title doctor to fool the patients into believing they are doctors. Er [sic] podiatrists use the
word consultant again to convince the patients that they are doctors, em [sic] and I always come back to the example that, I’m sorry the fact that
you’re a male, lots of patients will assume that you’re a doctor and the fact that you’re female, lots of patients will assume then that [tails off].” [MP
354-359]
Despite written information and verbal explanations, patients’ misconceptions and
assumptions often persist:
“I’m always saying to patients, no I’m not a, I’m not a doctor, I’m a
podiatric surgeon, oh sorry you’re a mister [as if patient is replying], so you know straight away they’ve got em [sic] an er [sic] in the leaflets it tells
them that they’re coming to see me and what I am, I’m a podiatric surgeon em [sic] em [sic] a consultant podiatrist, I mean yeah you’re not a doctor
but you’re as good as [as if the patient is stating this], and well, in terms of the foot, yeah I might be, but I’m not here to deal with a medical patient like
that, but then it’s the same with a diabetes person, he’s not gonna [sic] start – I know a bit about orthopaedics let’s start dealing with that [as if the
diabetes doctor were stating this]. You know, so everyone has their specialty and I think it’s about recognising it, so title tends to cause more of a problem
in litigation cases, where people believe it may have been misused or abused …” [MP 360-370]
5.3.5 The Effects of Title on Patients’ Perceptions
Practitioner-respondents discussed how specialist titles are perceived by the public:
4: It’s a double-edged sword in a way
9: Yeah 4: because sometimes public see the title specialist and they feel more at ease
erm [sic] you know 1: because you know what you’re doing
4 because the title, yeah 1: that’s what they perceive.
4: whereas conversely it puts you on a pedestal that some people have a sport of trying to knock you off it. [Expert Reference Group 119-126]
…also highlighting that any title will impact on public perceptions:
10: The public also like the title of Senior; she’s the senior one you know. Gen: Mmm
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10: you know I have heard that in the past 4: Or even just the title Podiatrist, oh you’re a Podiatrist, not a Chiropodist
10: Mmm [sic] even Podiatrist is still, people still like 4: think it’s more senior and not
10: Oh a Podiatrist must be more specialist than a Chiropodist [chuckles] [Expert Reference Group 127-133]
Title though is just one factor which affects the perception of service users.
Location, attire and gender also play a role:
“I think patients will automatically assume if they, particularly if they are
coming into a hospital and they’re seeing a male, particularly if they’re not in a uniform, they will automatically assume they’re a doctor. Em [sic] so
there’s a lot of assumption by the patient and even though you tell them and correct them some pick up on it, some don’t. But they should be given the ch
[breaks off], you know they should be given the chance…” [MP 370-375]
5.3.6 The use of Academic Titles
Perhaps because for the general public, the title “doctor” has become synonymous
with medical qualification, use of the academic title “doctor” in clinical situations
has become problematic:
“… look at your colleagues who are doing PhDs, who have got PhDs, doctor on clinic on a foot clinic, look how uncomfortable it is for them to use that
title of doctor, because the patient will assume, inappropriately very often that they can manage all aspects and care, care for all aspects of the care.
Well you know if they’re with a PhD was on nitric oxide infusion into the vaso novorum then that’s not really gonna [sic] make them a medic and I
think sometimes that is one of the perceived barriers for us.” [SS 595-601]
Such problems with academic titles in healthcare settings are not unique to podiatry.
However as MP intimates an element of discomfort on the part of medically trained
individuals who do not hold qualifications at doctoral level, may influence their
attitude towards those other health professionals who have worked for and earned
doctoral degrees:
“I think you have to be careful as well in, inside the medical ho[breaks off], institution how you use titles that you’ve got, whether it’s em [sic], I mean
and this goes for medics as well, but if you’ve got a, an honorary professorship is it right to call yourself a professor within the hospital, or is
it not. You have to be careful because again, the assumption there is you are a professor, that means you are very expert and you’ve proved yourself
within your field, but if it’s an honorary title awarded by probably a university then that doesn’t necessarily mean that, it’s often given because of
your services to the school or to the university, so I think you know, on and I know that is an issue with, with consultants, I know that’s an issue with some
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consultants who’ve got professional titles such as professor, who purposely
will not use them in the NHS, but they will use them for the titles that whatever Dean awarded say, at the universities they’ll use them em [sic], so
I think you’ve gotta [sic] be careful, that’s, that I think you know taking podiatrists out of it, it goes, it still, but it goes on across the board, you know
should you use the title doctor when you’re not a medical doctor. Well you know, you’ve earned it, then these haven’t got a PhD, most, a lot do now, a
lot of them haven’t got a PhD, you know it’s a difference, so [tails off].” [MP 375-390]
5.3.7 Alternatives to the Current Variety of Titles
During the second phase of data gathering possible use of alternative titles was
explored. Objections to the grammatically correct “podiatric diabetology” and
“podiatric diabetologist” were raised by the medical diabetologist respondents:
“…if it became official A, there might be confusion and B, you might rub a
few diabetologist up the wrong way.” [IM 396-398]
One diabetologist considered “diabetology” to be contrived, choosing not to use the
title himself:
“…I always describe myself as a diabetes doctor, em [sic] whether that’s just inverse snobbery I’m not sure, but I, I don’t use the word diabetologist I
think it sounds contrived to me [smiling] em [sic] but that, I just like simple terms.” [AT654-657]
Most objections centred on use by non-medical healthcare practitioners of what the
diabetologists considered to be a medical title:
“Well I, I must admit it [hearing podiatric diabetologist] sort of jarred a little bit. Because er [sic] it, well I suppose people are working towards that er
[sic] because er [sic] I think the normal connotation in British medicine at the moment is that the diabetologist is a sort of a doctor specialist in looking
after diabetic patients.” [IM 361-365]
“I think if you call them a podiatric diabetologist then they would be confused and thought to be a diabetologist, which is, but if as em [sic] so,
you’d have to be careful about that.” [OM 359-362]
… this may well provoke an adverse reaction from the Association of Clinical
Diabetologists:
“… you might upset diabetologists so to speak, em [sic] that, you’ll get,
you’ll get shouted at if you start [chuckles] talking about them being
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diabetologists, there will be strong words from places like the Association of Clinical Diabetologists and so on. [OM 375-379]
The grammatical format of podiatric diabetologist also raised objections from the
diabetologists:
“Er [sic] so when you think podiatric diabetologist, erm [sic] then you th [breaks off], you th [breaks off], sort of think of the noun diabetologist and
then you think of the adjective of podiatric, so you, I think there’s a little bit of confusion.” [IM 365-368]
“Diabetes podiatrist is different to podiatrists, podiatry diabetologists.”
[OM 363-364]
Though the difficulty in finding a clear, grammatically correct title was
acknowledged:
“…the trouble is that when, when you actually try and get an adjective from diabetes, it immediately sort of says you know they’re diabetic, you know like
diabetic podiatrist, or a em [sic] a diabetol, diabet [breaks off].”
“Er [sic] it could be misconstrued that it’s a podiatric diabetologist, that means it’s a diabetologist who’s sort of tinkering around with podiatry” [IM
374-375]
Some diabetologists linked the title podiatric diabetology to practice which was
extended beyond the currently accepted remit of diabetes podiatrists, encompassing
more of the general medicine of diabetes:
“That would imply they were spreading beyond podiatry and that its, and
this we were getting to a more generic diabetes specialism, cos [sic] we haven’t yet had any dia [breaks off] podiatrists who were adjusting insulin
for example or, or suggesting glucose lowering therapy, or hypertensive therapy, or, or lipid therapy, or the – what they’ve done so far is to say the
cholesterol is raised and needs treating, rather actually than prescribing for it. I think if we’re going to say its diabetology then it would need to embrace
the whole of, of the specialism, and at what, what sort of level and I, sorry and how far within that the podiatrists would want to go.” [AT 571-580]
The Society of Chiropodists and Podiatrists respondent linked the title podiatric
diabetology to formal recognition of the title and an agreed threshold at which the
title came into use:
“I have no problem with it [podiatric diabetology] being rolled out, but I think you need to have a formal recognition somewhere and possibly along
with the formal recognition er [sic], who is entitled, what’s the threshold to get, to get that recognition” [JB 685-689]
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5.4 So what? What IS in a name?
The data demonstrates that title can have potent effects, impacting on perceptions,
clinical activities, scope of practice and access to services. Clinicians experience the
effects of their titles and some have strongly held opinions regarding their
appropriateness. For clinicians use of specialist titles may be viewed as a step in
achieving what Hugman referred to as “internal closure”; allowing diabetes
podiatrists to assert their difference from generalist colleagues, point to their
ownership over knowledge and the solutions to the problems of diabetic foot disease
- and thus cast themselves in the “virtuoso role” (see section 1.7). Wilensky (1964)
also noted that changing professional titles, discarding those associated with low
status and replacing them with alternatives could be seen as a strategy to link new
titles with higher status.
Patients also experience the effects of clinicians’ titles, most overtly through the
accessibility of services. As the data illustrates inclusion of descriptors such as
“wound” reduce the access of patients with intact skin, regardless of the severity of
their disease, their need for management of non-wound problems and their
requirements for proactive, preventative care. Inclusion of a particular disease
within the tile can penalise patients who may have similar symptoms, pathological
processes and needs – but not the specified disease. While some podiatrists have
been able to negotiate access routes for non-diabetic patients, such access remains
informal and dependent upon many variable factors – manifestations of Strauss et
al’s tacit agreements and unofficial arrangements within the context of the
professionalized milieu which characterise the division of labour within the hospital.
The currently confused nomenclature in diabetes podiatry serves to further obscure
the often poorly understood roles and functions of podiatrists who specialise in
diabetes. While in some areas titles are assigned in a reasoned and purposeful
manner, often choice of title represents an attempt to use the parlance of health
service modernisation embodied in Agenda for Change – with little or no
consideration of the powerful effects of title. Clinicians highlight the use of the
word “specialist” as problematic; confusing, divisive and contentious – and the
application of the title specialist to relatively junior practitioners undertaking
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generalist roles. While specialist registrar and the Certificate of Completion of
Specialist Training (CCST) are terms used by medical doctors, use of the word
specialist in the titles by which their jobs are labelled is not overt. Instead the term
diabetology has been used in a grammatically correct from to indicate a focus upon
diabetes, thus simultaneously conveying the concept of specialised practice and
identifying its focus. While the general public may refer to them as “specialists” this
has become a lay term. This phenomenon has resonance with Macdonald’s (1995)
assessment of the word “profession” in which he highlights Freidson’s (1983)
description of it as a “folk concept”, a term used by laity. As such “one does not
attempt to determine what a profession is in an absolute sense” (Freidson 1983,
p27) but focuses on how professions are made and accomplished by actions.
Building upon Freidson’s perspective then, viewing “specialist” as a lay term leads
one to a focus on how specialty is achieved by the activities of social actors.
Through this author’s research, the evolution of podiatric specialisation in diabetes
has been linked to charismatic authority, medical patronage and the professional
project of a specific group of podiatrists; set against a background of increasing
numbers of people with diabetes, in an era characterised by “condition focussed”
and “risk stratified” health policy.
The terms “podiatric diabetology” and “podiatric diabetologist” would represent a
grammatically correct method of conveying the concept of specialised activity,
describing the focus of the activity and clearly identifying the practitioner as a
podiatrist, while avoiding inclusion of the problematic word “specialist” within the
title. However medical opposition to use of the words diabetology and diabetologist
may mean that such titles are not adopted; as lacking rational-legal authority and
unable to point to concrete legitimation for their specialty, podiatrists specialising in
diabetes still rely upon continued medical patronage (see sections 4.2, 4.5, 4.7.2 and
4.9). If reference to the condition of diabetes is to be retained within the title, then
“diabetes podiatrist” may then be the most accurate, grammatically correct title
available. However a title which has no overt reference to diabetes, but
encompasses the increased risks of ulceration and amputation brought about by
peripheral neuropathy, peripheral vascular disease or a combination of the two could
improve access to services for high risk patients who do not have diabetes; though
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this brings into question the ability of services to meet the likely increased demand
this may bring.
Within healthcare formulating, using, and legitimising a clear and consistently
applied title constitutes a key step in asserting ownership or jurisdiction over a
defined clinical area. As Abbott (see section 1.7.4) points out an effective link
between a professional group and its work at both micro and macro levels is a
crucial step in gaining external (social) recognition for such jurisdictional claims.
Title represents a potent means of creating such a link. For the podiatrists
specialising in diabetes naming both specialty and practitioner – thus claiming for
their defined group of podiatric clinicians specialty in the field of diabetes – remains
a key legitimating activity which has yet to be undertaken.
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6.0 Specialisation in Diabetes Podiatry
In addressing the question “what does specialisation in diabetes podiatry mean?”
variation and divisions were made explicit. Different levels of practice exist,
ranging from complete immersion in the diabetes podiatry role to part-time
specialty. Legitimating factors for diabetes podiatry as a defined specialty include
charismatic authority, medical patronage and patient risk stratification, embodied
within some sections of health policy.
6.1 Variation
All respondents agreed that diabetes podiatry is an area characterised by variation in
roles and responsibilities, knowledge and skills, standards and level of practice:
“…the standards of [pause] work that each specialist diabetes podiatrist
does will vary an awful lot, I think that is governed by their knowledge, [pause] or lack of it…” [MP 288-290]
“…some people …who are in specialist podiatrist’s posts may not have
anything like the responsibilities and the skills that others may have depending on where they find themselves.” [JH 589-591]
Even amongst the ten “lead” diabetes podiatrists who form the Expert Reference
Group, the opinion was that difference rather than similarity characterised their
activities:
“We’ve all got different jobs even round the table haven’t we, so it’s quite difficult to pick which one to go for cos [sic] we’ve got within this, this
meeting we’ve got people doing different roles …” [Expert Reference Group 175-176]
CG considered that the different levels of specialty could be formalised to provide a
more structured approach to diabetes foot care:
“…you could have a community specialist diabetes podiatrist, you could have a hospital-based specialist and you could have a specialist who actually
coordinates the whole of the diabetic foot-care for a locality, an area, a trust, a region …you can have the consultant, whatever he is at [band] 9, but
you could equally have a few consultants within the primary care within that region, that then liaise and coordinate, if you see what I mean, it’s like
command, a line of command. Em [sic] so I, I think em [sic] it, ideally it’s a difficult thing to ask I think because as I said I think that, that there are
levels of specialty and therefore specialists…” [CG 751-754, 760-764]
There is however an acknowledged absence of any standardised preparation or
educational credentials for specialisation in diabetes podiatry:
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“…there’s no set em [sic] recommendation for what makes a diabetes
specialist. So there’s nothing you can hang your hat upon and say that makes you a diabetes specialist, you can fill in your em [sic] job spec [sic]
accordingly around the national frameworks and things but still, you know there I don’t think there is one yet for a diabetes specialist, is there?” [MP
547-551]
Em [sic] well there is no em [sic] clearly recognised em [sic] training programme and Neil and I have and Louise Stuart have spoken many times
about developing a training programme for the diabetic foot. But it’s never really come to anything …” [OM 246-249]
Employment criteria can thus be problematic:
“…the employer hasn’t really got a clue then as to who is a specialist and who isn’t, because if there’s no le [breaks off] no standardised level of
education and training…” [BL 578-580]
…which leads some managers to prioritise experience over education:
“I’m not satisfied with the level of education as a determining factor of competence; I’m much happier knowing people’s experience.” [Faculty of
Management 43-45]
…with preparation for post following more of an apprenticeship model:
“…unlike medicine there isn’t a diabetes em [sic]there isn’t a required
progress for it to happen … its, it’s working with those podiatrists who, working as an assistant if you like in those pod [breaks off], in those clinics
where there are podiatrists with those skills and learning from them.”[AT 406-415]
Currently then control over diabetes podiatry rests with the employers who have
jurisdiction over the job descriptions, recruitment, selection and appointment of
diabetes podiatrists. Diabetologists have a lead role in preparing the job
descriptions:
“We did set up a job description [requiring]…somebody who’s worked in a
[diabetic foot] clinic – who has skills in casting, who understands, who understands the management of wounds and, and the aggressive
debridement of wounds, who can prescribe, this is your, this is your wish-list isn’t it? [AT 418-422]
6.2 Stratification
The advent of risk-stratification, which is embodied within the NICE guidelines for
diabetes, has impacted on the division of labour in diabetes foot care:
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“It’s assessment of the high risk, I mean years ago we didn’t have this whole thing of this is the high-risk patient, it was sort of yes, it was almost if they
felt they were diabetic high-risk and everybody has to have their nails cut by a podiatrist, whereas obviously now its assessing has this person got
neuropathy, have they got ischaemic problems, I think that’s, that’s the difference as well.” [Expert Reference Group 423-427]
Subsequent documents and clinical guidelines, perhaps most notably The National
Minimum Skills Framework for the Commissioning of Foot Care Services for
People with Diabetes (Foot in Diabetes UK et al 2006) have reinforced the approach
where increased levels of patient risk and complexity are to be met by practitioners
with more advanced knowledge and skills (see also the “stepped care model”). In
this way risk-stratification of patients has provided a legitimating factor in the
diabetes podiatrists’ claim to specialty.
6.2.1 A Divided Specialty
During data gathering and analysis divisions based upon level of practice and
practice location became apparent. Podiatrists fully integrated into a diabetes team
based in secondary care, with a diabetologist who had an interest in the diabetic foot
were able to immerse themselves in the role of diabetes podiatrist. Those podiatrists
who had worked in such settings were able to practice in the community at an
advanced level, utilising their charismatic authority and the access rights to services,
investigations and individuals which they had established while working in
secondary care. Podiatrists who had worked solely in community settings are
viewed with some caution by the hospital based diabetologists and diabetes
podiatrists, who highlight the need for “up-skilling” of such practitioners.
6.3 Immersion in the Specialist Role
In describing their roles and activities, complete immersion in the specialist role was
evident in the accounts of the diabetes podiatrists who worked within a diabetic foot
team, based in secondary care. Extended scope clinical activity such as prescribing
was highlighted, but important emphasis was also placed on research and
dissemination, policy writing, influencing practice and how diabetes podiatry is
perceived:
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Don’t sleep, that’s the key [laughing]. Em [sic] yes I’m going to do well this
year, I think I’m going to have 8, probably 8 publications this year… I mean my research I do in my own time, I’m here at 7 in the morning, I leave at 7 at
night, I work at weekends and nights em [sic] to do what I do, em [sic] and I recognise that not everybody’s an idiot like me and they do have a life em
[sic]” [CG 334-335, 582-585]
“…so I prescribe, the research, publish, er [sic] I’m involved in policy, influencing practice, involved in how other health care professionals see us –
which is a long road…” [SS 212-214]
6.3.1 Education
The educational preparation for role was seen in terms of depth (advanced higher
degree preparation) versus breadth (more knowledge at the same academic level) by
the Skills for Health respondent:
“…some people are gonna [sic] really love to get in there and do the research and therefore should follow that depth of knowledge route whereas
others may just actually like the hands-on experience of treatment and the gratification of doing the treatment and therefore would follow the breadth
route. [BL 471-475]
This respondent linked immersion in “the diabetic project” to knowledge, full-time
working and the need to inform future education and treatment:
“[a] diabetic specialist real specialist which as I say have got a depth of
knowledge, and you’re going to require that individual not to simply do treatment, but to start to push the bounds of knowledge, and work with a
team of people who may be attached to a university hospital, whatever it was, in order to function, you know erm [sic], as somebody that is going to
be informing the education in the future of people, you know, the full informing the treatment of all er [sic] diabetics in this area, then it would
make sense that they would spend their entire time on the diabetic you know, erm [sic] project so to speak.” [BL 418-425]
However the Skills for Health respondent also perceived some higher level
education, which equips practitioners to research and influence policy as
unnecessary for clinicians who focus solely on treatment:
“…and it would be unfortunate if somebody was trained for example in diabetes to become a really good researcher up to masters level education
and then ended up just simply doing treatments, dressing treatments on diabetic patients in a diabetic clinic. That could have actually been
accomplished by a podiatrist at the same level who had just had extended skills…” [BL385-390]
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This was at odds with the perspective of one senior diabetes podiatry clinician and
educator, who highlighted the complex judgement skills and higher level clinical
reasoning required to manage the multi-factorial needs of patients:
“ I think the higher level clinical reasoning skills with these very complex,
high risk individuals, who have got a tremendous lot of co-morbidities, polypharmacy, erm [sic] there’s a danger in making it’s, er, er [sic] in
breaking them into simple one or two line competencies. Er [sic] making the right call or judgement call can be em [sic], can be quite a sophisticated
cognitive process” [JH 379-384]
“I suppose my fear is we’re going down the Skills for Health of competency based route, and I can see politically that happening to a greater or lesser
extent. I can see people then dong some CPD just for the sake of the set of skills on their own in order to then to, to jump an educational process. I
worry that we haven’t got the evidence about the appropriateness of education programmes to make sure that the people do develop all the skills
and knowledge and attitudes that are really there. It worries me going down this kind of simplistic notion of a particular competency in isolation. [JH
792-799]
… and would seem to also contradict the perspective expressed within the Expert
Reference group who pointed to enhanced reasoning in the interpretation of clinical
signs:
“The advanced assessments seem to be the biggest thing with the prevention
isn’t it, cottoning onto a few more of the signals a little earlier than some of perhaps our colleagues.” [Expert Reference Group 420-422]
SS highlighted an on-going learning process for clinicians, articulating the notion of
a continuum of progress:
“…it’s a rolling continuum of progress and that you never actually become at your destination, you never finally become that diabetes specialist
podiatrist that doesn’t need any more training…” [SS 353-355]
6.3.2 Clinical Roles and Activities
Clinically activity across the domains of prevention, management and secondary
prevention was considered to be part of the remit; with advanced assessment and
some roles previously associated with medical doctors considered normal activities
for lead diabetes podiatrists:
“…it’s, it’s, it is broad prevention, acute management and then secondary
prevention, it’s all there.” [AT 53-54]
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“You possibly could even put under that advanced vascular assessment, you
know er [sic] depending what sort of specialist lead you are.” [Expert Reference Group 437-438]
“…obtaining, ordering and interpreting x-rays, bloods, interpreting bloods,
ordering bloods, knowing what bloods to order in what circumstances. Em [sic] different sorts of imaging MR, CT, ultrasound erm [sic] they’re all part
and parcel of what I would consider an extended role, anyone can order, it’s understanding what you’ve ordered and interpreting it.” [MP 134-138]
“I think you could also add in sort of medical proper problems such as
painful neuropathy, Charcot that sort of diagnosis and management of those for the lead specialist podiatrist.” [Expert Reference Group 429-430]
A particularly potent example of this role substitution phenomenon (see also section
2.0) was considered to be the activity of one podiatric surgeon whose working focus
has become foot salvage procedures for people with advanced diabetic foot disease:
“…and then at the extreme end you’ve got the podiatric surgeons who are actually on the work that the orthopaedic surgeons were doing before. And
that is, now I’ve reached the stage where my preferred referral is to, it’s across the city but it’s to a podiatric surgeon rather than to an orthopaedic
surgeon to do the structural work – and he was trained as a podiatrist not as a surgeon” [AT 67-72]
It was in fact a gap in service provision which allowed the podiatric surgeon under
discussion to establish a specialised role in diabetic foot-salvage procedures:
“…in our group of hospitals we don’t actually have an orthopaedic surgeon, or didn’t, it’s happened in the last year, in last year, we didn’t have a
surgeon with an interest in the foot” [AT 80-82]
“So I do all the diabetic foot surgery em [sic], which [sighs] er [sic] goes
well with the orthopaedics cos [sic] they don’t wanna [sic] do it, so that’s fine.” [MP 21-22]
Having established jurisdiction within this role, the current podiatric surgeon seems
likely to be able to defend it, though this may change if the either the surgeon or
diabetologist involved should leave:
“…whoever came now would have to be a very good technician surgeon to move me away from em [sic] the service that I’m using because er [sic] the
sort of outcomes that we’re getting, the sort of opinions, the sensible opinions, yes we should do something or equally good, no this is not
something that we need to do anything about. And to have absolute
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confidence, and when you’ve met someone that you have absolute confidence in you stick with them don’t you?” [AT 83-89]
Advanced knowledge of haematology and pharmacology were highlighted. Even
with status as supplementary prescribers, the podiatrists’ knowledge in these areas
was considered vital in providing an adequate service to patients:
“Erm [sic] bloods definitely, is something, a big issue cos [sic] you know if you’re looking at infection, if you’re not monitoring the bloods, how are you
knowing whether the infection is regressing, just purely looking on the topical side of it, you know, what are the bloods doing, are the antibiotics
interacting with the bloods, you know, you need to be aware of that and you need to monitor them closely…” [MP 138-143]
“I think having an understanding about all the drugs and how they affect and
what affects they might have, because many of these patients with type 2 diabetes are polypharmacy, the other various interactions, the other side
effects, knowing, knowing the, your, your sort of the, the pharmacology inside out helps … drugs the side effects, the problems understanding
antibiotics, revision of side effect when and where, interpretation of blood tests, interpretation of imaging techniques, erm [sic] these would probably
be quite important facets I would think.” [JH 280-287]
“… you may not actually be prescribing them, you may be doing them under PGDs, em [sic] but you need to be aware of what your interactions are, what
potential complications the patient may have with those drugs, what drugs may interact with other drugs. Em [sic] I think you need to be a resource
although you’re not ultimately responsible for that then, but you still need to have that knowledge and understanding cos [sic] otherwise the patient is
getting an inferior service.” [MP144 -149]
In providing patient education, advanced level knowledge and practice in
psychosocial medicine was highlighted:
Erm [sic] there’s a sort of twofold thing here about looking after people with
diabetes, there’s a sort of biomedical approach, clinical approach and then there’s a psychology approach which is probably more important than all
the biochemistry stuff … knowing about psychosocial medicine at a higher level [JH 276-278, 283-284]
“And the podiatrists I think are better at the education and therefore there’s
an educational role that comes with that em [sic], not just education but behaviour change, so actually understanding that is, is, is the important
aspect.” [AT 36-39]
“…the understanding of how education works, how you facilitate learning, erm [sic] dealing with erm [sic], dealing with various people with diabetes
[who] often have depression and psychological problems, issues, surrounding care for diabetes, having a, an in-depth understanding of the
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psychology, the psychosocial factors involved in diabetes is an extended
scope.” [JH 271-275]
Within what is termed “offloading” the diabetes podiatrists’ remit was considered to
cover the development of extended skills in plaster techniques, the subjective and
objective evaluation of offloading efficacy and liaising with the shoe fitter:
“…and possibly the high level of evaluating offloading, you know if you’ve
got any, any kit around, knowing how to use the kit, knowing what, what they’re doing and being able to develop both subjective and objective
measures of offloading techniques as well… [JH 287-290]
“…but it’s the offloading that’s important and understanding the biomechanics and actually offloading the fff [sic] the pressure from the feet
and to understanding what sort of devices are available and increasingly in, in our clinics they’ve had to develop the, what would have been plaster-room
skills, actually in developing the casting…” [AT 48-52]
“…there are a number of key people involved here and, and the podiatrist is one of the key people, the specialist podiatrist em [sic] so new developments
in the em [sic] offloading and bringing in the shoe fitter and relating with the shoe fitter is all Neil’s responsibility.” [OM 85-88]
Treatment of ulceration and extended knowledge and skills in wound management
were highlighted:
“…equally extended scope in understanding about wound management, understanding about maybe the chronic biology of wounds and how diabetic
wounds often, often develop into chronic wounds and understanding the biochemistry of, surrounding the differences and therefore having some
appreciation of which modern dressing might be useful, that sort of stuff.” [JH 271-294]
6: “I think everyone here probably deals with ulcers though don’t they; I know that, I think everyone
All: Mmm [nods and agreement] 6: so that is definitely part of the job erm [sic] wound management.
2: I think we do the bulk of the tissue viability responsibility for our districts 6: Mmm [nodding]
2: wherever we work.” [Expert Reference Group 187-193]
6.3.3 Case Management Roles and Activities
A key role for the diabetes podiatrist was considered to be coordination, referral and
communication activity:
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3: “But then it’s what happens afterwards as well, it’s coordinating 4: Yeah, no, it’s referring
3: Knowing when to refer on, to who and, and making sure that they get the necessary tests and feeding that back into, feeding that information back to
the GPs, feeding that information back to your colleagues and keeping hold of them and you know providing timely interventions and discharging them
back to the community colleagues at the right time as well.” [Expert Reference Group 439-444]
…and liaison:
8: “There’s a lot of liaison isn’t there between the Diabetologist, GPs,
Practice Nurses, District Nurses, colleagues, Vascular, Orthopaedic people even, it’s sort of tying that whole thing in [interrupted]
3: Having that knowledge of who to contact, when. 8: so the patient gets to see the right person.” [Expert Reference Group 446-
449]
…often directing the multi-disciplinary process and acting as the case manager:
3: “I think quite often we are the ones that actually coordinate the whole care, we are the ones that get them to see the Dieticians, Diabetic Specialist
Nurse, that get their footwear sorted out, to get them an appointment to see the Consultant. Initially they’ll come in as an emergency because of their
ulcer, they’ve just been sent er [sic] by the GP practice and it’s us that actually start the whole flow of the multi-disciplinary process off and I think
we provide a very important function in that.” [Expert Reference Group 472-477]
Respondents highlighted that this case management activity takes time:
6: “I mean I saw someone in a community hospital the other day and I ended
up ringing the Diabetic Nurses, the Diabetic Consultant and the Vascular Consultant and sorted them out 3 different appointments, so that was, that
was a 20 minute treatment and I was there an hour-and-a-half …” [Expert Reference Group 479-481]
…and requires insight into the patient’s circumstances, on occasions requiring the
diabetes podiatrist to act in the capacity of patient advocate:
6: “…this person needed to see all those, unfortunately they kept saying oh
she’s DNA’d appointments and I said that’s because she’s been in the St Georges’ in London, she been in, she’s an ill lady and she’s not purposely
DNA’d she, you know you sort of think, hang on a minute she, they say she DNA’d even though she was in the hospital where she was supposed to go
for outpatients, you know [laughs].” [Expert Reference Group 482-486]
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Clinician-respondents expressed concerns about being able to justify this non-
clinical case-management activity:
4: “…one of the big worries that we have is if you come across somebody who needs other input you spend a lot of time that is effectively non-clinical time
organising to try and get them the care that they need which can I think potentially in the long term could pose us a problem, even though we’re
doing the best for the patient, when it comes down to the bean-counters 6: Mmm [nodding] we’ve seen 4 patients
4: We’ve seen 4 patients yeah and you’re not cost effective because [interrupted]
3: People look at your activity rather than how much you save them in the long run because of what you’re coordinating
4: And that’s very, very hard to quantify 6: You do like a District Nurse, you know the amount of times you ring up to
arrange the District Nurses to go and visit 3: It’s very hard to quantify what we do in many ways isn’t it. Some of the
added value that we have that gets hidden, people don’t see what we do 1: Yeah
3: and 4: and it’s quite hard to, if you were, if you were forced into a position where
you had to justify what you did, it would actually be very hard to sell it to a commissioner …” [Expert Reference Group 703-720]
The difference between accessing the multi-disciplinary team and working within a
consultant-led multi-disciplinary clinic was highlighted by the Expert Reference
Group respondents:
4: “I do a clinic erm [sic] one session fortnightly it is actually a joint clinic with the consultant, so its dedicated consultant time, a consultant led foot clinic.
But like everyone else the rest of the time effectively you’d regard it as an open door policy so people have the multi-disciplinary contact on an
informal basis on a needs, needs basis, rather than necessarily have a one-stop-shop whether they need it or not which is financially a waste of money”
[Expert Reference Group 699-703]
For podiatrists, integration within or “open door access” to the multi-disciplinary
diabetes team facilitates access to hospital-based services, led by medical
consultants. This ability to access medically-led services is linked to immersion in
the diabetes podiatry role. If podiatrists working in the community are able to
establish and maintain the right to refer directly to such services, they are still able to
function as specialist practitioners. Those diabetes podiatrists able to practice at
advanced levels in the community do so by using their charismatic authority, the
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referral routes, access to imaging and investigations which they have established in
the secondary care arena:
“…for example in Salford, Tameside you’ve got the Martin Foxes of this
world and so and so forth who’ve developed a primary care pathway, em [sic] and if you ask Martin, it’s tenacity again and working in a secondary
care centre, getting known as a bit of an expert in there and then working in primary care and developing care pathways and things within, within that.”
[CG 370-374]
“… [a specific diabetes podiatrist who worked extensively in secondary care
and is now working in the community has] direct access to again, to the vascular surgeons and to me [a diabetologist]. So if she saw people in the
community clinic she could offer an opinion and say no I don’t think this needs referral, if it needed referral then she could go straight on into the
vascular clinic and, and they would be seen quickly and very often then straight on to invasive investigation if needed. So it took out a step if you
like. Or onto the clinic to see me [a diabetologist]” [AT 366-342]
On a practical level then, the GPs’ control over the referral process may be the
largest barrier to diabetes podiatry functioning as a specialty in the community.
Though future medical support for diabetes services in the community need not
necessarily rely upon GPs:
“What I don’t know is gonna [sic] happen is that there are now four highly
sss [sic, breaks off] highly trained, highly specialised diabetes specialist podiatrists in the community … and I see absolutely no reason why they
shouldn’t set up their own specialist diabetes clinic in the community. Who they would get to provide the medical support I don’t know. It could be a
specialist GP or they could b [breaks off], I mean in these days of commissioning you can but it from anyone.” [AT 715-723]
6.3.4 Leadership of Services:
Managers considered the ability to work within and lead a team and integration with
a range of health professionals to be definitive factors for specialist status:
1. “…the role is very much about the, the, the way in which people will be
working, [clears throat], not just their clinical knowledge and skills it, it, what is essential, critically essential is their ability to work in a team, to be
able to lead er [sic] the team, to be able to integrate and work with consultants and GPs and a whole range of other people, in a partnership
way, that’s fundamental, the, the, the key skills and knowledge em [sic] er [sic], they’re more than just a bonus but, but, but without the other factors
somebody wouldn’t be a specialist.” [Faculty of Management 54-61]
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Leadership skills were also valued by diabetologists:
“…I was fortunate enough here and I had a podiatrist, more than one podiatrist who was perfectly capable of leading the service. You need it to
be in conjunction, it’s a partnership, but no em [sic] the podiatrist I had was driving things” [AT 16-20]
Managers agreed that a specialist role should be dedicated, highlighting a remit to
work across organisations and partnerships, influencing practice and change within a
specific, unique area:
1. “…for me that, that specialist role has to be dedicated erm [sic], because it has to work across other organisations and partnerships to influence practice and
change you know, in, in a specific and unique area.” [Faculty of Management 118-120]
6.4 Part-Time Specialisation
Utilising service-level-agreements (SLA) some podiatrists are employed as part-time
specialists to work both in the community and within the hospital-based multi-
disciplinary-team:
“…they were specialist diabetes pod [breaks off], em [sic] podiatrists when they were here, but actually when they were working in the community they
would do the general work…still doing general type podiatry, in, in general clinics in the community – and probably two days a week were specialists
here. [AT 223-228]
One of the major problems cited with part-time specialist activity were issues of
accessibility and availability to act as a resource for both patients and other staff:
“So you’ve got to be very much accessible, which is one of the reasons why I
say I don’t believe you can be a diabetes specialist podiatrist 1 or 2 days a week. I believe it should be, you know 7 days a, 7 days, 5 days a week, and
you’ve got, it should involve, if you’re not there, there should be other people within the team that can be contacted.” [MP 124-128]
Though the Skills for Health respondent considered that:
“…you need to have an understanding that there can be people, who can
deal in a specialist diabetic clinic, who are not themselves actually regarded as specialists” [BL 593-595]
…and that the non-specialist podiatrist may have a comparable clinical impact to a
specialist diabetes podiatrist:
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“I mean at the end of the day, the person who’s just a di [sic], just added, just added skills to the same kind of academic level, thinking, erm [sic] and
does a Friday afternoon say with a specialist diabetes team, just maintaining the diabetics’ foot, may still have the same impact on patient care and you
know, and have the same impact on, on erm [sic] success rates in terms of keeping limbs and things, as somebody, as a podiatrist who’s part of a team
that has been there because they’ve got additional depth of knowledge and research skills, you know.” [BL 345-353]
6.4.1 Community Podiatrists
Concerns regarding the expertise and practice of community podiatrists were voiced:
“Well in my experience [community podiatrists refer patients in] later than
they should. There are a lot of community podiatrists who have a reluctance to refer the patient on because they quite enjoy treating the ulcers and the
challenge of it and sadly some of them will wait too long.” [PL 258-260]
“Em [sic] there are a lot of people out there with various degrees of podiatry who are doing things and doing them badly and causing harm, more harm
than good and that is, the profession needs to do something about that. And until they do something about that, em [sic] I think that they are doing
themselves an injustice, they will not be looking, I mean there’s a lot of quibble about podiatry in the community in general because of this sort of
thing. [OM 405-411]
The practice and education of an “intermediate” level of podiatrists was considered
to require attention:
“At the moment it’s, you know, the patient who doesn’t need to come to the
[hospital] clinic but needs podiatry within the community could be seen by anyone and I think that’s something that podiatry has, more than sorting out
the specialists, they need to sort out that intermediate group” [OM 400-404]
…this in some areas is addressed by clinical rotations within the diabetic foot clinics
for the community podiatrists:
“…so there’s quite a lot of involvement of the community podiatrists within
the [hospital diabetic foot] service. Em [sic] so everyone’s hopefully up-skilled a bit [looks directly at researcher]. [OM 72-74]
“…from the podiatrists’ point of view it’s in order to keep the skills up, is, is
to allow a broad base of people that are out there in the community that can manage and recognise foot disease but who have the opportunity to come
into the specialist entre and keep their skills up.” [AT 820-824]
Dysfunction between community podiatry and secondary provision was cited as a
major barrier to providing integrated services:
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“What we should have is an integrated service across community and
secondary care. And with ideally podiatrists who are working across both sectors, allow, which allows the patients to be, what you were saying to be
managed closer to home. Em [sic] but that can be brought in, I mean it’s horrible that “seamlessly” word, but can be brought into the specialist clinic
when they need that.” [AT 808-814]
…with an ethos of competition and divisive funding and governance structures cited
as the barriers preventing integration of services:
“…I think what we do need is that better integration of the service. Which
we know and which we’ve tried to aspire to, but it’s very difficult when someone else is funding the service out in the community…it’s not so much
separate funding its, its governance I suppose over the structure…” [OM 498-501, 506-507]
“…at the moment it’s the, the current organisation of the NHS, it has been
divisive, I you, I’m sure you’ll detect a hobby-horse coming on now – I, I feel that it has been divisive and retrograde, you know and splitting the PCT
between commissioning and providing arms in itself is divisive, but actually making us compete, making secondary care compete with the em [sic]
provider arm of the PCT has been divisive”. [AT 871-876]
6.5 Focussed Specialty in Diabetes or Multi-Specialists? Differing Perspectives
While part-time specialty drew criticism in terms of accessibility, the issue of multi-
specialty proved to be more contentious:
4: I would have said that was a retrograde step because if you’re a specialist in everything then you’re a master of, you know it’s that old thing of the GP,
general practitioner is a jack of all trades and a master of none. If you’re a specialist, you wouldn’t have a diabetes consultant who was also a
rheumatologist, who was an orthopaedic surgeon etcetera, etcetera and I don’t [interrupted]
8: Misuse of the term of specialist really isn’t it 4: Yes
All Mmm [nods and agreement] 4: What they are asking for is, is a
2: General Practitioner really [Expert Reference Group 216-225]
Faculty of Management respondents reached consensus that specialising in multiple
areas limits the role and practice of the specialist, their ability to change and
influence practice and what is achievable by the specialist in terms of being able to
influence change generally. Further, Faculty of Management respondents agreed
that a specialist role should be dedicated, highlighting that the specialist’s role is to
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work across organisations and partnerships to influence practice and change in a
specific, unique area:
1: But it [multi-specialty] has to be limited doesn’t it,
7: Yeah 1: if, you know I mean you’re, the ability of that person to influence change you
know and practice has to be limited if, if their roles swing across a range of erm [sic] a range of disciplines. I mean I only work in a, you know a largish
organisation and, and for me that, that specialist role has to be dedicated erm [sic], because it has to work across other organisations and
partnerships to influence practice and change you know, in, in a specific and unique area. [Pause] I don’t see how it [multi-specialty] can, I don’t see how
it can be done, I mean I know that in many structures it has to be done [Faculty of Management 113-122]
Where clinicians are required to cover for others during busy times concerns about
governance were voiced:
1: “Well, well I have some governance concerns about that, you know, really
it’s, it’s you know, how, how can somebody do that, how can you necessarily be able to audit you know the work across those areas, you know keep up to
date, you know with, with research, practice you know and all sorts of things, it, it I think that must be you know hugely difficult, for, for anybody to try and
achieve.” [Faculty of Management 134-139]
While recognising these major problems, some Faculty of Management respondents
pointed to the fact that within some organisations they had no choice but to ask
clinicians to act as multi-specialists:
7: Well it depends on the size of your team, cos [sic] if you’ve got a small team
you’re gonna [sic] have people who are gonna [sic] do say one day a week of everything, so you’re gonna [sic] cover everything, so I’ve the experience
of working in a small team where you’re doing one day of diabetes, one day of musculo-skeletal work, but in a larger team where you, larger department
when you split into teams and you’ve got a set sort of clinical leads, pathways, whatever, and designated area and people sort of stay in that
area, em [sic] so there’s a real difference between size of the department and the roles that are required for that person and if you’ve got full-time
members of staff, part-time members of staff, what they’re gonna [sic] bring to it, job share – if you’ve got somebody coming in to do a post and you’ve
got 2 people who want to job share, what’s, have they got equitable skills?[Faculty of Management 101-112]
Aspects of workforce flexibility were also cited by the Skills for Health respondent:
“…if it’s about actually additional skills at the same academic level, say extending your breadth of knowledge, well that’s OK as well in many ways, I
mean basically you could have the person do diabetics clinics on a Friday
182
and rheumatology clinics on a Thursday, you know these sort of things.”
[BL146-150]
Three of the four Foot in Diabetes UK key actors considered being asked to cover
multiple specialist areas to be inappropriate on many levels:
“Get stuffed. I think it’s a cheek em [sic] a cheek. I can’t see how you can expect somebody to em [sic] really, really excel spreading yourself so thinly.
I wouldn’t dream of calling myself an expert in rheumatology and biomechanics, I know a reasonable amount about them and I can hold my
own, but there is no way on earth I could argue with a specialist physio [sic] in rheumatology. I em [sic] you know, maybe I’m missing the point, maybe I
could direct what they do or, or facilitate them to do what they do em [sic] but is that what they want? No I don’t think that’s what they want when they
advertise these [posts to cover multi-specialist areas], they’re not asking for managers, they are asking for clinicians. If we’ve got all these problems
about what is a specialist in diabetes it’s equally true for those other areas and how are, can have got your specialism in, I mean you must be 150 as far
as I’m concerned [laughter] to go for one of those posts and have been working for 149 years, em [sic] I think it’s a, I think it’s a real cheek, I really
do em [sic] and I think you’re em [sic] watering down skills and specialisms by doing that, personally.” [CG 889-901]
One person doing the, crossing over all those skills. Em [sic] I think it’s very unfair to the person who em [sic] would apply for such a post. Em [sic] I
think that it’s possible to, to have spent some time, depending on where you find yourself, but to be a specialist in more than one area is a nonsense. Erm
[sic] although in diabetes you would have to have a degree of expertise in biomechanics, infection control etcetera, er [sic] the, there’s some generic
skills across, they, they go across the boundaries of the specialisms. But I think if you’re going to have a specialist post and to be championing the em
[sic] education and training for others, championing management planning, being part of the team and organisation, running education programmes,
providing all the various levels of support, etcetera in a, it, it would be aye totally unfair on the individual to expect them to, to cover more than one,
one area. A jack of all trades at general post level yes, a specialist across areas is, is, is, is farcical and would be an insult to both the patients and to
the person that’s, I don’t, I just don’t think you’re doing the job really properly in every facet of what that leadership might mean, you couldn’t possibly be in more than one specialty. [JH 602-615]
In justifying specialty focussed on diabetes, the complex nature of the disease and its
management was cited:
I guess it was about 17 years ago when I first started working here that I
really became very passionate and focussed on diabetes research and managing all sorts of diabetes and em [sic]. I just think it’s such a complex
183
disease and it blows my mind that people can be specialist in more than one area, that they can kind of specialise in musculo-skeletal and diabetes, I
think whoa cos [sic] you know I’ve been specialising in diabetes for 17, 18 years minimum I mean at times I still think I’m on the first rung, you know
you learn something and then you take 4 steps back and think whoa well I know nothing and everyone says you know nothing and everyone thinks
what, and I say no I don’t. [SS 14-22]
The clinician-respondents who had experienced multi-specialist working considered
that specialising in more than one area was not feasible:
3: “… I used to be a rheumatology and a diabetes specialist and I found it impossible to juggle the two to be quite honest
6: Yeah I used to have rheumatology in clinic and trying to do the two, although it was interesting you almost have to [interrupted]
5: you didn’t feel that you were, I didn’t feel that I was getting anywhere with it 6: because rheumatology almost needs, you’ve gotta [sic] be, have time to do
the insoles and do this and 3: It’s getting back to CPD as well
1,4,5,6:Yeah 3: You know to, to juggle two is going to be very, very difficult nowadays as 4
was saying you, you’re gonna [sic] be a master of none if you’re gonna [sic] juggle them. I think we’re very much should be going down the specialist
route and there’s just so much learning out there the emphasis on evidence based practice means that a lot of time is having to be put into us actually
keeping up with best practice, gold-standard services and I don’t think you can know everything.” [Expert Reference Group 231-244]
Medical specialties were cited as models, concerns were voiced about the ability of
practitioners to specialise in multiple areas and the service delivered to patients:
I must a complete lunatic, because as far as I’m concerned to take on a speciality other than diabetes and arterial disease and the work that I do
now, mmm [sic] it blows my mind, it would blow my mind. I mean you don’t get a rheumatologist / endocrinologist / neurologist. And I just think oh well
there are some people that its within their capability to do that, but how much justice can they do to a patient and certainly in my province they give
100% to diabetes or to arterial disease, CV and I’m learning a lot a little bit late. So I, I have concerns about being all things to all men, it’s to what
degree can you, can you do them. [Pause] [SS 660-668]
…though one Foot in Diabetes UK key actor acknowledged that some medical
practitioners also covered a general caseload:
Take, take the average diabetes physician, endocrinologist, he doesn’t spend his full time doing endocrinology, he does some general clinics as well, er
[sic] up on the ward, medical wards, so if we’re looking at any role models
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of people then they don’t spend all of their time in that one specialty. [JH
642-646]
The Skills for Health participant expressed concerns over focussed specialties:
“…the mind set at the present moment is that if somebody is regarded as a
specialist in, in diabetes then they can’t be a specialist at something else. The issue I have with it is that you never have a, s [sic], you should never be
considered a specialist in one role without understanding what, you never, you never vacate the baseline education, and that’s what some people do. So
I know somebody, I did know somebody that actually was em [sic] called themselves a diabetic specialist and wouldn’t touch biomechanics with a
barge pole and never actually did anything in terms of increasing their understanding of biomechanics. Such that they didn’t really understand that
really, you know, if you don’t mechanically, if you don’t pr[breaks off], make the f [breaks off], give the foot the ability to function mechanically soundly,
then that may actually have additional stresses that has an implication on diabetes and the complications of diabetes. And that is a danger, where
people start specialising without that understanding, you know. Erm [sic] you know, so I’ll only treat diabetics, I’m not interested in the rest of things,
I’m not interested in d, biomechanics, I’m not interested in rheumatology, I’m a diabetic specialist. [BL 173-189]
This point was echoed by one of the Foot in Diabetes UK key actors, who
emphasised that a range of advanced knowledge was required in order not to limit
specialist practice:
“… I mean in terms of diabetes you’ve again got some overlap because you
do need an understanding of biomechanics, you do need an understanding of pressure relief, and I think that’s where some people are cocking up at the
moment, is because they are looking at pressure relief and forgetting mechanics, so I think that’s one of the reasons why certain devices fail,
because they’re forgetting the mechanics of what’s going on with the patient. So in essence, my feeling would be that to be a specialist in biomechanics, or
diabetes, or rheumatology you need an understanding and a good understanding of all those and I’d say beyond a basic podiatrist, but then
you could specialise in one area and take that several stages further, but as a, for arguments sake as a bio-mechanist, you know if you’re just gonna [sic]
do biomechanics, are you gonna [sic] totally exclude diabetes, are you gonna [sic] totally exclude rheumatology? So I would say there’s, there’s a place for all of them together but you need to specialise further into one… As
a specialist do I think you could exclude yourself from either of those? – No I don’t believe you could. And if you are, you are gonna [sic] be very limited,
in terms of what you can do, and do I think you’re probably really fulfilling a specialist role? I would question it. A lot would hate me for saying it …”
[MP 628-639, 643-646]
185
While some Diabetes Specialist Podiatrists acknowledge a lack of advanced
biomechanics knowledge and skills, they also highlight their retention of baseline
knowledge in the area and their ability to access colleagues with such advanced
knowledge and skills:
a lot of us have probably left behind things like er [sic] biomechanics skills, we retain the basics but when you actually see what some of your musculo-
skeletal colleagues are doing and specialising, you realise how far they’ve gone ahead of you now…[Expert Reference Group 250-252]
One diabetes podiatrist highlighted the difference in biomechanics of the diabetic
foot, citing this - along with soft tissue mechanics as one of many special interests:
Em [sic] the diabetic foot, full stop, per se. Em [sic] so I’m interested, real
specialist, or real, real em [sic] keen interests are soft tissue mechanics, [clears throat] Charcot, em [sic] just got submitted a couple of papers to
Diabetes Care on Charcot, with some research I’ve just done, em [sic] the micro-circulation, ulceration and its management, I think we, just go on and
on really footwear, biomechanics and the diabetic foot, they, it’s not quite the same as in the normal foot, and peripheral arterial disease. [CG 37-42]
…while another pointed to the emergence of a sub-specialty to address diabetic foot
biomechanics:
I think you can even sub-divide specialisms even further. What we’re attempting to do at the moment is cross-overs between biomechanics and
biomechanical problems in a diabetic er [sic] with musculo-skeletal people we’ve actually got somebody who’s got a foot in both camps that er [sic]
doesn’t necessarily do loads of diabetic foot clinics er [sic] but is actually specifically looking at those that we recognise as needing a biomechanics
specialist to look at, and she will liaise with both us and with the musculo-skeletal guys for best care so, so I think you could even start dividing down
specialisms…[Expert Reference Group 309-315]
So, while all Faculty of Management, Expert Reference Group and three of the four
Foot in Diabetes UK participants expressed the view that specialty in diabetes
podiatry should ideally be a focussed, sole specialty, concerns were raised by the
Skills for Health and one Foot in Diabetes UK participant. These concerns when
explored centred on lack of workforce flexibility and limitations to clinical skill and
activity imposed by inadequate or incomplete advanced knowledge.
6.6 Implications of Specialisation in Diabetes Podiatry
Focussed activity in one clinical area requires that practitioners reduce or cease
activity in other areas:
186
“…once you start specialising, once you do that, then you’re reducing your
breadth of knowledge, you’re reducing your breadth of practice…” [BL80-82]
3: “judging by how my departments gone em [sic] you know it is a case of use
it or lose it in some ways and a lot of us have probably left behind things like er [sic] biomechanics skills, we retain the basics but when you actually see
what some of your musculo-skeletal colleagues are doing and specialising, you realise how far they’ve gone ahead of you now, and likewise when you
talk about diabetes they don’t want to know because they realise we’ve gone far ahead of them so I think specialist route and just go down one route is
important and crucial.” [Expert Reference Group 249-255]
…leaving gaps in provision:
“…if you’re a podiatry department if you’ve got some people who are
operating in a greater depth and a narrowing base, then you need to replace that person in the other skills that are missing…what you’ve got to start
thinking of then is what other specialists do I need to fulfil the other roles?” [BL 125-130]
In this way establishing one specialty acts as a driver for the establishment of other
specialist areas:
1: “… I know about diabetes and there’s someone else that leads rheumatology.” [Expert Reference Group 258-259]
6.7 The Current Status of Diabetes Podiatry
Being primarily driven by different individuals, geographically distant from each
other and working for a variety of employers it is unsurprising that there is wide
variation in the role and activities undertaken by diabetes podiatrists. The divisions
between community and hospital based practice in diabetes podiatry were
highlighted by respondents; the keenness with which they assert such differences
probably representing one facet of their internal closure strategy. Though some
podiatrists already established as diabetes specialists are now functioning in the
community, they do so by utilising their charismatic authority and contacts
established whilst working in secondary care. The move to community-based
services and GP commissioning may prove to be a challenging time for the
specialty; diabetes podiatrists cite GP’s lack of exposure to and poor knowledge of
diabetes podiatry (section 4.5).
187
There are factors which legitimate the diabetes podiatrists’ claims to specialist status
and conversely factors which undermine such claims:
The acknowledged lack of accredited, nationally recognised training significantly
undermines claims to legitimate specialty. In discussing training for diabetes
podiatrists tensions between the Skills for Health competency focussed approach to
training and development and the acknowledgement of higher cognitive skills and
reasoning were elicited. These tensions embody the difference between the concepts
of technicality and indeterminacy discussed by Jamous and Peloille.
Understandably clinicians are more likely to highlight the indeterminate, untestable
knowledge which reinforces their autonomy, while Skills for Health are more likely
to focus on technical skills which can be codified and communicated in the form of
rules.
Developing pre-requisite training and a route to career progression is likely to
require significant data to inform its contents, including information on the current
workforce which is currently lacking. Research to address this deficiency has been
commenced; during the course of this researcher’s PhD she was contacted by
another doctoral student just beginning her studies who wished to conduct a series of
diabetes services and workforce surveys. This aim linked closely with that
expressed by a particular diabetologist and diabetes podiatrist – so with the
permission of all parties this researcher facilitated contact so that these aims could
be advanced. A diabetes workforce survey is now underway.
As Andrew Abbot highlighted formal qualifications are only part of legitimacy –
evidence of effectiveness is also important. Through on-going clinical audit and
publication of data some diabetes centres have evidence of efficacy in reducing
ulceration and amputation rates, though this data speaks to the effects of the multi-
disciplinary team rather than diabetes podiatry per se. The blend of condition focus
and risk stratification which is extant in current health policy provides a further
legitimating factor in diabetes podiatrists’ assertion to specialty, allowing them to
claim a high status, limb and lifesaving role - Hugman’s virtuoso role (sections 1.5,
1.7, 1.7.3 and 5.4). The successful launch of the National Minimum Skills
Framework for the Commissioning of Foot Care Services for People with Diabetes
188
and latterly NICE guideline 119 (2011) Diabetic foot problems. In-patient
Management of people with diabetic foot ulcers and infection represent further
legitimating and exclusionary strategies. In encouraging employers to adopt what
Freidson terms institutional credentialing (see section 1.7.2.1), diabetes podiatrists
have been able to set a threshold level for diabetes podiatry provision whilst
strengthening their jurisdictional claims.
However for diabetes podiatrists a clear and formalised route to progression and pre-
requisite training remains elusive, leaving claims to legitimacy relying upon
charismatic authority, medical patronage and small sections of health policy. Thus,
the specialty remains vulnerable. Set against the current economic climate and under
the influence of competing forces the future of diabetes podiatry as a defined
specialty is far from certain.
189
7.0 Results – Documentary Analysis
Between the years 1945 and 2010 within the journals searched, advertising for one
thousand, one hundred and three chiropodic and podiatric jobs in clinical and
educational practice met the criteria for specialist posts (table 23. Advertising of
Specialist Posts 1945-2010).
7.1 Descriptors and Titles
Descriptors and wording of advertising show changes over time, exhibiting a move
from the generic term “chiropodist” attached to a description of a specialist post;
then through the addition of suffixes to indicate an area of specialist focus; onwards
to the assignment of specialist titles; and, latterly the use of specialist titles attached
to descriptions of generalist posts (table 23. Advertising of Specialist Posts and fig.
3. Advertising of Specialist Posts – changes over time).
190
Table 23. Advertising of Specialist Posts 1945 to 2010
Year 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62* 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10 Total
Specialist
post
described 1 3 5 4 3 2 3 1 1 1 1 2 1 4 0 0 2 3 2 2 1 2 2 2 3 2 7 5 5 3 5 5 9 5 4 6 9 1 11 21 17 17 10 12 7 1 4 1 1 2 5 4 6 5 5 5 6 1 4 1 1 264
Specialist
post & title
(pod.ed.) 4 2 5 4 5 6 13 5 5 9 4 5 5 3 4 9 2 6 2 4 7 4 3 2 5 4 6 2 1 4 7 3 16 2 1 4 7 1 6 7 3 8 3 5 3 4 220
Specialist
post & title
clinical 3 1 2 3 5 2 9 8 19 28 29 46 46 51 18 16 13 6 2 307
Specialist
post, title &
credentials
(pod.ed.) 3 1 4 8 8 7 1 2 5 3 6 1 2 4 3 5 5 2 1 3 1 1 1 1 4 2 5 2 5 8 2 8 2 3 2 3 3 127
Specialist
described&
credentials
clinical 2 2 1 1 3 1 1 1 12
Post+suffix
indicating
specialty 2 3 1 1 4 5 3 8 6 6 10 3 3 1 1 57
Spec. post,
suffix &
credentials 1 1 1 1 4
Specialist
post, title&
credentials
(clinical) 1 3 6 10 7 15 13 5 4 5 2 1 72Specialist
title but
generalist
post 1 6 14 12 7 40
Total 1 3 5 4 3 2 3 1 1 1 1 2 1 4 0 0 2 7 4 7 4 6 8 15 10 8 12 15 18 18 10 9 11 23 10 16 9 15 8 19 29 24 27 16 21 15 8 7 6 12 12 27 13 26 31 41 59 62 71 80 83 47 40 31 13 6 1103
191
Fig. 3. Advertising of Specialist Posts – changes over time
0
10
20
30
40
50
60
45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97 99 1 3 5 7 9
Specialist post described
Specialist post & title pod.ed.
Specialist post & title clinical
Specialist post, title & credentials pod.ed.
Specialist described& credentials clinical
Post+suffix indicating specialty
Spec. post, suffix & credentials
Specialist post, title& credentials (clinical)
Specialist title, generalist post
192
7.2 Specialist Areas
Advertisements were placed for posts within thirty three defined specialist areas
across clinical practice and podiatric education (table 24. Advertised Specialist
Areas 1945-2010 and fig. 4. Advertised Specialist Areas 1945-2010), of which posts
in podiatric education were the most numerous (344 posts). Specialist positions in
the clinical areas of diabetes (176 posts), biomechanics (105 posts) and multi-
specialist positions (102 posts) were the largest groups; diabetes combined with
tissue viability or wound care roles adding to the overall diabetes total (a further 5
posts).
7.3 Grading and Banding
Grades began to be assigned to posts during 1976. Table 25. Advertised Specialist
Posts by Grade 1976 onwards, clearly illustrates that senior I was the commonest
grade assigned to specialised posts and that diabetes was the commonest graded
specialty area. The advent of Agenda for Change brought with it a new banding
system which became evident in job advertisements from 2005. Table 26.
Advertised Specialist Posts by Band 2005-2010 demonstrates that generalist posts
became the most frequently advertised area (included in the data due to the
allocation of a specialist title), though only one of the thirty six generalist posts was
graded at “band 6 or 7”, with the remaining thirty five being at band 6 or below.
Within the advertised posts meeting the inclusion criteria, band 7 positions occurred
most frequently.
193
Table 24. Advertised Specialist Areas 1945-2010
Year 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62* 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4 5 6 7 8 9 10 Total
Rheumatology 1 2 1 1 1 1 2 1 10
Orthopaedics 1 2 2 1 1 1 1 1 1 2 1 1 1 1 1 18
Pod ed 1 1 5 2 5 4 5 6 13 8 5 10 8 13 13 7 4 5 14 6 10 3 6 7 8 6 7 10 6 7 5 1 1 5 7 2 16 6 3 9 9 2 14 12 11 10 6 7 6 4 3 344
Paediatrics 1 1 1 2 1 1 1 1 1 2 3 3 1 2 3 2 4 2 2 3 1 2 2 1 2 3 2 1 3 1 4 3 1 63
Diabetes 1 3 1 1 1 1 2 1 1 1 2 3 1 3 1 1 1 1 3 1 2 1 1 3 3 2 2 4 7 11 24 17 15 17 17 3 10 6 1 176
Sports 1 1
Multi 1 1 1 1 1 1 3 1 1 2 2 4 1 3 4 5 1 4 4 2 4 1 4 6 2 1 2 6 1 6 3 2 4 5 4 3 2 2 1 102
footwear manf 1 1
Geriatrics 1 3 1 1 1 2 1 10
Appl. Manf. 1 2 1 1 3 4 3 2 1 1 1 20
High Risk 1 2 1 2 2 1 3 1 1 14
Biomech. 1 1 6 1 3 2 2 1 1 3 1 4 10 15 10 18 18 1 4 2 1 105
Prev/Health ed 1 1 2 1 1 1 1 1 1 1 1 2 14
Research 1 1 1 1 1 3 1 1 2 2 1 1 2 1 1 1 1 22
Nail surg. 2 1 1 1 1 1 1 1 9
Minor surg. 1 1 3 5
Wounds 1 4 5
Longterm cond 1 5 3 1 10
Pod. surgery 1 1 2 1 2 6 5 7 5 4 11 9 7 3 1 3 68
Clin. Gov. 1 1 2 4 1 1 10
Tissue Viab. 1 1 1 3
Adv. Pract. 2 1 1 4
Vascular 1 2 3
Rehab. 2 1 3
Wound+highri. 1 1
Footwear fittng 1 1
Re-profiling 1 1
MSK 1 7 4 13 2 3 2 32
Diabet+wound 1 1 2
Diabet+TV 2 1 3
Triage 1 1
Technician 1 1
Generalist 1 6 14 12 7 1 41
Total 1 3 5 4 3 2 3 1 1 1 1 2 1 4 0 0 2 7 4 7 4 6 8 15 10 8 12 15 18 18 10 9 11 23 10 16 9 15 8 19 29 24 27 16 21 15 8 7 6 12 12 27 13 26 31 41 59 62 71 80 83 47 40 31 13 6 1103
194
Fig. 4. Advertised Specialist Areas 1945-2010
0
5
10
15
20
25
30
45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 87 89 91 93 95 97 99 1 3 5 7 9
RheumatologyOrthopaedicsPod edPaediatricsDiabetesSportsMultifootwear manfGeriatricsAppl. Manf.High RiskBiomech.Prev/Health edResearchNail surg.Minor surg.WoundsLongterm condPod. surgeryClin. Gov.Tissue Viab.Adv. Pract.VascularRehab.Wound+highri.Footwear fittngRe-profiling
195
Table 25. Advertised Specialist Posts by Grade 1976 Onwards
1976- Not stated Tech. Assistant Sen II Sen I /II Sen I S. I/ Ch. IV Chief IV Chief III ChiefIII/II Chief II Training Post House offr. Registrar Consultant MC21 F/G Total
Rheumatology 7 7
Orthopaedics 1 1 1 1 4
Paediatrics 2 4 37 3 5 1 52
Diabetes 14 1 5 1 82 5 13 1 2 1 1 126
Multi 4 6 1 61 3 5 80
Geriatrics 3 2 5
Appl. Manf. 1 10 3 4 18
High Risk 1 12 4 17
Biomech. 10 5 64 3 13 95
Prev/Health ed 1 1 10 1 13
Research 2 3 5 2 1 13
Nail surg. 4 3 7
Minor surg. 2 1 3
Wounds 1 3 4
Longterm cond 1 2 3
Pod. surgery 15 4 2 1 2 19 4 7 3 1 58
Clin. Gov. 3 4 2 9
Tissue Viab. 2 2
Adv. Pract. 1 3 4
Vascular 2 1 3
Rehab. 2 1 3
Wound+highri. 1 1
Footwear fittng 1 1
Re-profiling 1 1
MSK 2 3 1 1 8 15
Diabet+wound 1 1
Diabet+TV 0
Triage 0
Generalist 4 1 5
Total 59 1 7 27 2 322 2 24 61 1 8 19 4 7 4 1 1 550
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Table 26. Advertised Specialist Posts by Band 2005 to 2010 2005- Hon. Contract Not stated 4 5 5 or 6 6 6 or 7 7 7 or 8a 8a 8b 8c 8d 9 AHP Consultant Total
Rheumatology 0
Orthopaedics 0
Paediatrics 1 1
Diabetes 1 2 16 3 1 1 24
Multi 1 2 5 1 1 10
Geriatrics 0
Appl. Manf. 1 1
High Risk 0
Biomech. 1 1 8 1 11
Prev/Health ed 0
Research 1 1 2
Nail surg. 1 1 2
Minor surg. 1 1
Wounds 0
Longterm cond 1 1
Pod. surgery 2 1 2 2 2 9
Clin. Gov. 1 1
Tissue Viab. 1 1
Adv. Pract. 0
Vascular 0
Rehab. 0
Wound+highri. 0
Footwear fittng 0
Re-profiling 0
MSK 2 1 2 7 7 19
Diabet+wound 1 1
Diabet+TV 2 2
Triage 1 1
Generalist 7 4 2 11 1 36
Total 2 12 1 6 2 35 1 45 1 11 1 3 2 2 1 125
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7.4 Specialist posts with diabetes component
Focussing on specialist posts in diabetes, advertising for positions was sporadic up
to 1969, with 2, 3, 4 or even 5 years elapsing between advertisements (table 24.
Advertised Specialist Areas 1945-2010 and fig. 4. Advertised Specialist Areas 1945-
2010). From 1994 posts in diabetes were advertised every year, though until 2000
the annual numbers remained in single figures. Combining the advertising for all
specialist posts which may have incorporated diabetes as an element of their clinical
workload yields a total of 283 posts over the 65 year period from 1945 to 2010 (fig
5. Advertised Posts with Possible Diabetes Component).
Fig. 5. Advertised Posts with Possible Diabetes Component
7.5 Discussion - Documentary Analysis
The gradual change from describing a specialised post, through addition of a suffix
to indicate the focus of specialisation, and then the subsequent attribution of
specialist titles (table 24. Advertising of specialist posts 1945-2010) corroborates
data derived from the focus group interviews; wherein respondents asserted that
specialised posts were extant before specialist titles. Latterly under the Agenda for
Change banding system specialist titles have been assigned to generalist posts, again
echoing the data from the interview respondents who considered that the term
0
5
10
15
20
25
30
35
45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99 2 5 8
198
“specialist” had become devalued and inappropriate because of its application to
generalist posts. Assigning these posts to bands 5 and 6 - with one instance of
grading at either band 6 or 7, infers status commensurate with more junior
practitioners, lending weight to the argument that the phenomenon is likely to
represent the employer’s bid to speak the language of health service modernisation,
rather than evidencing an extension of specialisation.
Within the clinical and specialist groups identified, podiatric education would appear
to be the most successful. Advertised posts were the most numerous, specialist titles
were assigned early in its evolution and underpinning credentials rapidly became a
requirement. This may reflect the pre-existence of an organising structure within
education; and particularly the well-defined hierarchy of higher education with its
titles, career structure and pre-requisite qualifications. In a similar vein the specialty
of podiatric surgery appears to have utilised the titles and model of career
progression associated with medical surgeons.
Advertisement of posts focussing on diabetes as a defined clinical area evidences the
existence of diabetes podiatry as a specialty – corroborating the assertions of
interview participants. Analysis of advertised podiatry posts focussing on diabetes
indicates that the specialty evolved gradually and haltingly from 1947 onwards,
concurrently with multiple other areas of specialised activity.
Focus group and key actor respondents considered that diabetes became established
as a specialist podiatric area towards the end of the 1980s. While advertising data
does show some increase at this time, there were only eight posts advertised within
this specialty between 1985 and 1990. The most notable increase in the frequency
of advertised specialist posts in diabetes being from 1994 onwards, reaching a peak
in 2001 when a total of 24 posts were advertised. This may indicate that the small
increase in posts during the last five years of the 1980s was considered to be
significant by respondents; there may have been further posts which were not
advertised – or which were advertised in media not sampled during this research; or
the firmer establishment of diabetes as an identified specialist area may have
occurred later than respondents recounted – coinciding with the increasing numbers
199
of advertised posts from 1994. The assertion that diabetes podiatry became
established towards the end of the 1980s may however evidence a significant impact
perceived from what was actually a small increase in numbers of diabetes
podiatrists. This may be a reflection of the charismatic nature of the individuals
involved and their application to the professional project - resulting in a perceived
impact far greater than that for which the numbers can account.
The decline in advertised specialist posts (and indeed advertising for all podiatry
posts) from 2009 is noteworthy, representing an effect of the changing health
economy of this time – bringing with it uncertainty for the future of specialist posts.
200
201
8.0 Summative Discussion
The questions which prompted the process of enquiry were broad, reflecting the
exploratory nature of the research. The questions focussed on the meaning of
specialisation in diabetes podiatry, how it evolved as a specialty, the impact of
specialist titles, the wider professional impact of specialised practice and the
sustainability of diabetes podiatry as a defined specialty. In answering these
questions, findings fell into three domains. Each domain has been presented and
discussed separately as have the findings from the documentary analysis. Some
issues however cross the boundaries between the areas already presented.
Some podiatrists and diabetologists working in secondary care were keen to assert a
difference between their practice and that of podiatrists working in the community
(see 6.2.1 and 6.4.1). Closer inspection of this area reveals that such differences are
far from clear-cut. Advanced podiatrists working in the community care for a
predominantly medium to high risk diabetic population Holland et al (2002). While
some secondary care practitioners are eager to cite the need for further training of
community podiatrists (see 6.2.1 and 6.4.1), the isolated nature of community
practice (Bending and Foster 2002) has historically been a clear limiting factor on
the level of practice. The lack of independent prescriber status also impacts more
markedly on those practitioners working in the community, where supplementary
prescribing and preparation of care management plans become more difficult due to
decreased access to medical support (see 4.7.1 and 4.7.2). Part-time specialty,
utilising service level agreements has long been a feature of diabetes specialist
podiatry (see 6.4) and more recently, community based specialist practice in diabetes
is becoming more common (see 6.3.3). Thus, the eagerness with which differences
are asserted is likely, at least in part to represent one facet of the diabetes specialist
podiatrists’ internal closure strategy (6.7) and a degree of protectionism.
The increasing number of roles assigned to the diabetes specialist podiatrist appears
to have been a driver for the establishment of a “diabetes specialist podiatry
assistant” grade (see 4.3, 1.5.6.1 and 1.6.2.3), considered by Holland et al (2002) to
have a pivotal role within secondary care. However as Hugman (1991, p94)
highlights assistants have ambiguous status, for while they derive their nature from
202
the profession with which they are associated, they are simultaneously excluded
from that profession – “being neither entirely distinct nor entirely integrated”. The
role of the diabetes specialist podiatry assistant (table 5) appears to be more
extensive than that with which the Society of Chiropodists and Podiatrists (2006a
and 2006b) policy of supervision for assistant grades (appendix 2) can be reconciled.
As Nancarrow and Borthwick (2005) point out delegation of roles to assistant grades
may well represent a means to maintain control over low status work, whilst also
allowing the specialist podiatrist to focus on higher status activities (see 1.7.3).
Within this chain of task shedding, there is though a duty to ensure that delegated
roles are left with capable individuals (see 4.3).
Agenda for Change has had a major influence on titles and banding within podiatry
and the diabetes specialist podiatrists have not been immune from its effects. While
cessation of appointment for podiatric surgeons under MC21 contracts may arguably
unify the profession (all podiatrists now being graded using the same system), this
may be felt by the surgeons to have diminished their status. Motivations for and
response to the Agenda for Change process has been variable. Some trusts have
retained old titles in a bid to maintain an expression of post seniority and
differentiation, whilst other trusts have retained old titles to minimise possible
divisive effects of the new titles which they perceive to be hierarchical (see 5.3.2).
Where the Agenda for Change nomenclature has been adopted it appears to have
added confusion to an already complex area, with many respondents being unsure of
the banding structure (see 5.1) and some respondents being unclear regarding their
own titles (see 5.2). The data brings into clear focus the implications of titles which
can have potent effects on access to services (5.3.1), clinical activities (5.3.1), the
ways in which the title-holder is perceived and their status as clinicians (5.3.2, 5.3.4
and 5.3.5). This changed status has legal as well as professional implications
(5.3.3), altering the level of practice deemed acceptable and increasing not just the
patients’ expectations but also the clinicians’ accountability under the law. Thus
practitioners may be held to account for their specialist titles and posts.
Weber’s concept of charismatic authority has formed a guiding theoretical concept
within this research, illuminating the way in which a defined specialty was created
203
and disseminated, in the absence of codified or credentialed authority. The
charismatic leaders acquired a following of other podiatrists and cultivated a
legitimate place within the larger medical specialty of diabetology. The existence of
stratified manifestations of charisma is manifest through the presence of
intermediate members of the charismatic band such as the “Expert Reference
Group” respondents. These practitioners are not the contemporary “key leaders” or
“champions” who succeeded the early “iconic leaders” in diabetes podiatry (see
4.4.1), however they are illustrative of the dispersed (though unequal) nature of
charismatic authority throughout the hierarchy of roles within such groups and the
existence of attenuated forms of charisma in a number of individuals (see 1.10.4).
Charismatic authority offers a compelling explanation not just for the evolution of
the specialty, but also for changes over time as routinisation strategies are employed
in a bid to secure its long-term future.
8.1 Quality of the Research
Throughout the research process the researcher has sought to maintain quality and
transparency, substantially informed by Yin’s (2003) perspective. Justification for
the methods of enquiry, the rationale for methodological decisions, data handling
and analysis approaches have been have been presented. The ontological and
epistemological underpinnings of the work have been discussed (section 3.1) and the
author’s status as a podiatrist with an interest in specialisation has been made
transparent.
The initial concept analysis assessed the maturity of the concept of the diabetes
specialist podiatrist. It traced the origins, change over time and current status of
podiatric specialisation in diabetes as well as the comparable cases of medical and
nursing specialisation in diabetes. Literature pertaining to the legal implications of
specialist practice, settings and titles was reviewed and a definition of specialisation
within the context of healthcare proposed. Flowing from the concept analysis
research questions which directed further enquiry were refined.
Because answers to the research questions are within the knowledge and
experiences of key actors, managers and individual podiatrists; a qualitative
methodology featuring focus group and key actor interviews was utilised. The
204
meaning of podiatric specialisation in diabetes, how diabetes evolved as a podiatric
specialty, the impact of specialist titles and the longer-term, wider implications
which accompany specialisation were explored. Verbatim transcription was
followed by a detailed and rigorous coding process, this was tabulated and is clearly
accessible to scrutiny; thus it is readily auditable and meets requirements of
transparency detailed in Yin’s chain of evidence approach (Yin 2003). In presenting
analysis of the data, the researcher focuses on theory which illuminates the findings.
The centrality of Weber’s concept of charismatic authority to the development and
contemporary face of specialist practice is illustrated by the data; thus it represents a
guiding theoretical concept within the author’s thesis.
Documentary analysis was used as a triangulation strategy, in a bid to corroborate
findings elicited through interview techniques. The documentary data also
illustrates both the scale of and the context within which podiatric specialisation in
diabetes evolved – not in isolation, but rather as one of many specialist foci.
While the author makes no claims for generalisability, the possible wider
applicability of this work cannot be ignored. Podiatry is just one of the fifteen
Allied Health Professions regulated by the Health Professions Council. Most have
degree level qualification as a minimum entry requirement and are considered to be
of similar status. Based upon this and the way in which other Allied Health
Professionals have identified with the work, expressing strong resonance with
themes of medical patronage and charismatic authority, applicability and
explanatory powers for a wider community of professions seem likely. The findings
from this work are substantive enough to indicate that there may be commonality
across some of the Allied Health Professions and possibly other professions.
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9.0 CONCLUSIONS
This research has analysed the concept of specialisation and evaluated the maturity of
the concept of diabetes podiatry as a defined specialty. This process allowed the
framing of a proposed definition for specialisation within the context of healthcare,
elicited difficulties with the term “specialist” and exposed the immaturity of the
concept of specialised podiatric practice in diabetes.
The centrality of charismatic authority in the establishment and development of
diabetes podiatry has been illustrated, as has its on-going and potent influence in
shaping the contemporary face of this podiatric specialty. Illustrations of the effects
of charismatic authority at micro and macro levels have been provided. The potential
tensions between charismatic leaders in podiatry and medical doctors have been
illustrated and discussed, as have the mechanisms which allow the charismatic’s
authority to be contained. The fragility of charismatic authority has been recognised
and contemporary attempts at routinisation which represent a bid to secure a
legitimate long-term future for the specialty have been discussed.
The evolution, change over time, meaning and current status of diabetes podiatry has
been explored, the forces that have driven and influenced its journey considered and
social theories which offer illumination discussed. The impact of and difficulties with
specialist titles have been explored and reasons examined. In considering “specialist”
a lay term a possible route to reducing difficulties with nomenclature may be
available, though this would require amending titles used under Agenda for Change.
The future sustainability of diabetes podiatry as a defined specialist area in the face of
further major health service reforms remains an unanswerable question; dependent
upon not just the authority, activities, professional project and negotiations of diabetes
podiatrists in legitimising and marketing their specialty, but also on the opinions,
choices and purchasing power of the new consortia.
9.1 Limitations of the Study and Future Directions
Because the clinician respondents within this research were either Foot in Diabetes
UK executive committee members or “lead” diabetes podiatrists their experiences are
of complete immersion in the diabetes podiatry role. Their knowledge and
206
experiences were thus invaluable in building a picture of full-time, focussed practice
in diabetes podiatry - with some respondents able to make experiential or insightful
comments on part-time specialty and multi-specialty. In order to gain a fuller picture
of the roles and activities undertaken by podiatrists practising on a part-time basis
within the diabetes specialty, further research will be required. This will in part be
addressed by the diabetes podiatry workforce survey however qualitative data from
part-time diabetes podiatrists will be required to build a picture of the specialty in its
broader form.
This work has explored many aspects of specialisation but has remained within the
professional and sociological domains – reflecting the impact of the research
questions. The effects of specialisation on practitioners at the personal and emotional
level has not been explored or evaluated. While some clinician respondents
mentioned emotional highs and lows and the impact of dealing with frequent limb-loss
or death amongst their patients, the researcher’s opinion was that in order to do justice
to this area a dedicated in-depth study would be required. Such a study would be
prompted by research questions focussing on the personal and emotional domains,
exploring psychological aspects beyond the scope of the work presented within this
thesis.
In using diabetes as an exemplar of podiatric specialisation other specialised areas
have not been explored. The author makes no claims for generalisability, recognising
that in focussing on a specific manifestation of specialisation and group of specialists,
the findings remain specific. While the evolution, changes over time and status of
podiatric surgery have been comprehensively addressed (Borthwick 1999, 2000) and
core podiatry has been defined and evaluated (Farndon 2006) other facets of podiatric
practice remain largely unaddressed. Further study of defined specialities within
podiatry such as rheumatology and biomechanics would serve to illuminate the
origins, evolutionary changes and current status of these areas, serving to build a
larger picture of podiatry as a profession. A quantitative study to evaluate the
generalisability of the research findings elicited during the author’s work presented in
this thesis would pave the way to a fuller understanding of specialisation. Such a
quantitative work need not be confined to diabetes, or indeed to podiatry. In
presenting her work to audiences from the wider allied health professions, the author
207
has found that the themes of charismatic authority and medical patronage have strong
resonance for other health professionals; raising the possibility of their utility as a
conceptual framework to illuminate specialisation more widely.
9.2 A personal reflection
In undertaking research training, through the experience of framing, organising and
executing this research, in interacting with other researchers and in writing this thesis
– endeavouring to illuminate findings with pertinent theory – the author has learned a
great deal. This learning has covered philosophical, practical and personal domains.
Within the practical sphere time management and organisational skills have been
tested and honed, IT skills developed (accompanied by some frustration and the odd
cross word), writing skills improved and presentation skills learned. On a personal
level juggling the pressures of competing demands has compelled the author to reflect
on her priorities. In considering the ontological and epistemological underpinnings of
her work the researcher gained insight into the bond between the research questions,
research area and researcher. It is this more than anything which will modify her
approach to her future research. Throughout research methods were selected on the
basis of utility in answering the research questions with the aim of conducting
exploratory research in a hitherto unaddressed area – which would be subsequently
amenable to extension and refinement through future work.
208
209
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APPENDICES
1. Overview of the sample p236
2. Society of Chiropodists and Podiatrists policy of supervision
for assistant grades p237
3. Copies of interview schedules p239
4. Participant information sheets p257
5. Participant consent forms p273
6. Example of coding p275
7. Example of interview transcript p276
236
Appendix 1
Overview of the sample
Pseudonym Status
SS
CG
JH
MP
PL
Expert Reference Group 1-10
Faculty of Management 1-8
BL
JB
IM
OM
AT
Specialist Podiatrist
Specialist Podiatrist
Specialist Podiatrist
Specialist Podiatrist
Specialist Podiatrist
Specialist Podiatrist
NHS Manager
Skills for Health respondent
Society of Chiropodists and Podiatrists respondent
Diabetologist
Diabetologist
Diabetologist
237
Appendix 2
Society of Chiropodists and Podiatrists
Guidelines on delegation and supervision of Assistant Practitioners and Footcare Assistants
Delegation If you elect to delegate a task, or temporarily transfer the care of a client or patient to a footcare assistant or assistant practitioner, you are responsible for the outcome. You must ensure that you have appropriately assessed the patient and that the person to whom you have delegated:
1. Understands what is expected of them and has a clear written treatment plan with expected outcomes with target dates
2. Has the knowledge, skills and recognised qualification or experience to carry out what you have asked them to do safely and effectively
3. Is appropriately supervised 4. Is aware of when and under what circumstances the patient should be
referred back for a reassessment 5. Is able to refer the patient back to you or another Podiatrist without
delay, if they are uncertain or concerned in any way as to the patient’s changed health status or their response to the treatment being provided
If they tell you that they are unwilling or unable to carry out a particular task or to continue with the care of a particular patient, you must not endanger the patient by forcing them to do so. You should explore the reasons and identify any training issues before making any decisions as to what to do. Supervision Delegated work should regularly be reviewed in line with the agreed treatment plan. The appropriate level of supervision can only be defined in terms of the knowledge and skill of the footcare assistant or assistant practitioner, according to the guidance in table 1 overleaf. For assistants operating at level D and above, it will not be necessary for them to work in the same location as the supervising podiatrist.
238
Table 1: Guidelines on the supervision of Assistant Practitioners and Footcare Assistants Level Description of theoretical
knowledge Description of technical and operative skills
Appropriate supervision
A Having to ask or be told what to do
Podiatrist showing: Assistant helping
Direct Supervision B Aware of what to do, but
not really knowing what to do
Assistant undertaking the work: with the podiatrist helping
C Confident in their underpinning knowledge but not able to demonstrate that knowledge in the clinical setting
Assistant doing the work: with a podiatrist overseeing their work
Indirect Supervision
D Understands what to do and able to do it
Assistant doing: with Podiatrist available within the clinical environment
E Able to develop their knowledge and build on it during practice. Able to research and critique knowledge and use it wisely
Assistant doing: with Podiatrist available for advice
Proximal Supervision
239
Appendix 3a. Interview schedule for Podiatry Managers (focus group)
Introduce self/ thanks Outline of the nature of focus groups/ aims of today’s focus group
Introductory questions: Issues around language and terminology in Diabetes Specialist Podiatrist recruitment
and job descriptions:
How do you choose the wording of advertisements for Diabetes Specialist
Podiatrist posts and job descriptions? What are your reasons for choosing
specific terms?
Do you draw distinctions between experience and education [specialisation] in
job recruitment advertising?
What is the effect of advertising for multi-specialist skills? (i.e. one post to
cover diabetes, rheumatology and biomechanics specialist areas - e.g. advertisement for Plymouth pod dept. Oct 05 Pod Now)
Drivers for Diabetes Specialist Podiatry
What factors influenced your decision to employ a diabetes specialist
podiatrist? [What are podiatry managers responding to with specialist roles? What motivates managers to advertise these jobs? Are National Service
Frameworks a driver? Is specialism a means of enhancing Agenda for Change profile of posts? Is specialisation seen as a form of career
progression?]
Role of the Diabetes Specialist Podiatrist
What roles and functions do you require of your Diabetes Specialist Podiatrist
staff?
Are these roles undertaken by any other professions?
In what ways do you consider the Diabetes Specialist Podiatrists’ role to be different from that of other (generalist) podiatrists? [are there any facets of
Diabetes Specialist Podiatry activity which can be clearly identified as “extended scope practice”? or are the roles extensions and refinements of
those taught in the undergraduate syllabus and as such practiced by most podiatrists at some time in their career?]
Issues around sustainability:
How long have Diabetes Specialist Podiatrist posts been established within
your service? [Origins of DSP. Can podiatry departments sustain specialist posts?]
How are the requirements for Diabetes Specialist Podiatry met? [e.g. 1 day/week from community etc.]
For how many hours per week are your Diabetes Specialist Podiatrists employed in their specialist capacity? [Mismatch between demand and drive
for specialisms? Do services demand specialist roles? Is 5 days a week in specialist diabetes care possible and sustainable?]
Ways of working
Do your Diabetes Specialist Podiatrists work with other professions? [skill mix,
isolated or interdisciplinary approach; capture organisational differences between services]
240
How is care planning undertaken for clients with diabetic foot disease? [Joint
planning or co-located but separate professions? If joint is this led by one profession or is it a team process?]
Accessing Diabetes Specialist Podiatry services
From whom do your Diabetes Specialist Podiatrists take referrals?
When do podiatrists within your service refer clients to the Diabetes Specialist
Podiatrist? [How does the process work? use of guidelines or referral pathway; education for “community” podiatrists; is a “shared care” model used?;
tensions between generalist and specialist podiatrists ;why should general podiatrists refer to DSPs?]
How many specialist roles can podiatry support?
Does your service employ other identified specialist podiatrists? – In what
areas? For how many hours per week?
Impact on service of specialisation:
How, and by whom are the needs of the other service users not encompassed in
the specialists’ remit met? [reduction in general/core podiatry? re-profiling of caseload? core/generalist podiatrists’ role and status?]
How does your service meet the podiatry needs of non-diabetic clients?
Education and/or experience [craft based models/professionalisation… Is there a sheltered position within the podiatry labour market for Diabetes Specialist
Podiatrists?]
What education do you consider to be an absolute pre-requisite for the post of
Diabetes Specialist Podiatrist? [Impact of lack of approved training for “specialists”]
What experience do you consider to be a pre-requisite for the post of Diabetes
Specialist Podiatrist? [Impact of lack of formalised career pathway for practitioners to develop specialist skills/status]
Status/remuneration
How do you choose the grade and salary of Diabetes Specialist Podiatrist posts?
Vision of ideal Diabetes Specialist Podiatrists’ role, ideal educational preparation for
Diabetes Specialist Podiatry + barriers
Having spoken about the current reality, what would the ideal Diabetes
Specialist Podiatrists’ role be like? [Vision of Diabetes Specialist Podiatrists and Diabetes Specialist Podiatry service in an ideal world – would Diabetes
Specialist Podiatrists work in their specialism full time?; aspirations for the future of the service; long-term objectives]
…… and the ideal educational preparation for Diabetes Specialist Podiatrists?
What prevents us from achieving this ideal situation? [what are the barriers]
Snowball sampling
…and finally are there any other people you feel have a contribution to make
concerning the themes we have discussed today? [Who else should I be talking to about these themes? Which other groups or individuals would wish to have
241
their voices heard on these matters? Who else may make valuable contributions to this data?]
Anything you wish to add?
242
Appendix 3b Interview schedule for key “Foot in Diabetes United Kingdom”
members
Introductory questions:
How did you become a Diabetes Specialist Podiatrist?
What are your particular interests in the field of Diabetes Specialist Podiatry?
Drivers for Diabetes Specialist Podiatry:
In your opinion, what factors have influenced the development of diabetes
specialist podiatry? [ Are National Service Frameworks a driver? Is specialism a means of enhancing Agenda for Change profile of posts? Is
specialisation seen as a form of career progression?]
Role of the Diabetes Specialist Podiatrist
What do you consider to be the roles and functions of a DSP? [Specialised
activities or core podiatry for diabetic clients? Do perspectives differ
significantly from the managers’?]
In your experience, are these roles undertaken by any other professional
groups? (inter-professional jurisdictional boundary issues?)
In what ways do you consider the Diabetes Specialist Podiatrists’ role to be
different from that of other (generalist) podiatrists? [are there any facets of Diabetes Specialist Podiatry activity which can be clearly identified as
“extended scope practice”? or are the roles extensions and refinements of those taught in the undergraduate syllabus and as such practiced by most
podiatrists at some time in their carer?]
What do you think distinguishes Diabetes Specialist Podiatry from general
podiatry? [is there anything about the organisation, professional orientation or career path which is different for Diabetes Specialist Podiatrists?]
Ways of working
In your experience, do Diabetes Specialist Podiatrists work with other
professions? [skill mix, isolated or interdisciplinary approach; capture organisational differences between services]
In your experience, how is care planning undertaken for clients with diabetic foot disease? [Joint planning or co-located but separate professions? If joint is
this led by one profession or is it a team process?]
Education and/or experience [craft based models/professionalisation… Is there a sheltered position within the podiatry labour market for Diabetes Specialist
Podiatrists?]
What education do you consider to be a pre-requisite for the post of Diabetes
Specialist Podiatrist? [Impact of lack of approved training for “specialists”]
Would you envisage additional training if activities such as altering insulin
regimes becomes part of the Diabetes Specialist Podiatrists’ remit?
-What form do you consider such training may take?
What experience do you consider to be a pre-requisite for the post of Diabetes
Specialist Podiatrist? [Impact of lack of formalised career pathway for practitioners to develop specialist skills/status]
In your opinion what are the legal implications of adopting specialist titles?
243
Issues around sustainability:
To your knowledge, how long have Diabetes Specialist Podiatrist posts been
established? [Origins of DSP. Can podiatry sustain specialist posts?]
In your experience, for how many hours per week are most Diabetes Specialist Podiatrists employed in their specialist capacity? [Mismatch between demand
and drive for specialisms? Do services demand specialist roles? Is 5 days a week in specialist diabetes care possible and sustainable?]
Accessing DSP services
To your knowledge, from whom do Diabetes Specialist Podiatrists take referrals?
In your experience, when do (general) podiatrists refer clients to a service
where Diabetes Specialist Podiatry is established? [How does the process work? use of guidelines or referral pathway; education for “community”
podiatrists; is a “shared care” model used?; tensions between generalist and specialist podiatrists ;why should general podiatrists refer to DSPs?]
Status/remuneration
In your experience what grade and salary do Diabetes Specialist Podiatrists receive? [does this reflect the documented reality gained from analysis of
Diabetes Specialist Podiatry recruitment]
What grade and salary do you consider appropriate for Diabetes Specialist
Podiatrists and why?
Vision of ideal Diabetes Specialist Podiatrist role + barriers
Having spoken about the current reality, what is your vision of the ideal
Diabetes Specialist Podiatrist role? [Vision of Diabetes Specialist Podiatry service in an ideal world – would Diabetes Specialist Podiatrists work in their
specialism full time?; aspirations for the future of the service; long-term objectives]
What do you think prevents us from achieving this ideal situation? [what are
the barriers]
Issues around language and terminology in Diabetes Specialist Podiatry recruitment and job descriptions: [if there is time]
In your opinion, how accurate is the wording of advertisements for Diabetes Specialist Podiatry posts/job descriptions in describing the role and activities of
Diabetes Specialist Podiatrists? [FDUK / personal perspectives on the language and terminology used to describe DSP]
Which terms do you consider to be the most appropriate?
What do you consider to be the effect of advertising for multi-specialist skills?
(i.e. one post to cover diabetes, rheumatology and biomechanics specialist areas
- e.g. advertisement for Plymouth podiatry department October 05 Podiatry Now) [Does this denigrate the skill level and importance of specialisms?]
Skills for Health
What is your opinion of the diabetic foot sections of the Diabetes Framework produced by Skills for Health? [Competence frameworks “Undertake
advanced examination and risk assessment of the feet of an individual with diabetes” (DF01), “specialist foot treatment for an individual with diabetes”
244
(DF02) and “provide wound care to treat an ulcerated foot of an individual with diabetes” (DF03)
Snowball sampling
…my final question, which other people you feel have a contribution to make
concerning the themes we have discussed today? [Who else should I be talking to about these themes? Which other groups or individuals would wish to have
their voices heard on these matters? Who else may make valuable contributions to this data?]
Anything you wish to add …
245
Appendix 3c. Interview schedule for focus group “Expert Reference Group”
Thanks, introduction, the reason I am accessing your group: highlighted by
other respondents in the research study as a source of important information
and insights
Focus Group Interview- tool to gather info from a group of respondents at one
hit. No need for consensus, captures variety in ways of working etc.
Please would you introduce yourselves, give the title of your post and say a few
words about your service Introductory questions:
How did you come to specialise in diabetes podiatry?
What are your particular interests in the field of Diabetes Podiatry?
Issues around language and terminology in Diabetes Specialist Podiatry – titles, legal implications, recruitment, job descriptions and access:
In describing podiatrists who specialise in diabetes podiatry, I have used the title “Diabetes Specialist Podiatrist” because this is the most commonly used
title in the literature, though I am aware that there is debate about its appropriateness. What is your preferred title and why? [prompts can be
“variety of different titles “lead” “DP” “DSP” “Cons Pod (diabetes)”]
In your opinion, what are the legal implications of adopting “specialist” titles?
In your opinion, how accurate is the wording of advertisements for Diabetes
Specialist Podiatry posts/job descriptions in describing the role and activities of Diabetes Specialist Podiatrists?
Which terms do you consider to be the most appropriate?
What do you consider to be the effect of advertising for multi-specialist skills?
(i.e. one post to cover diabetes, rheumatology and biomechanics specialist areas - e.g. advertisement for Plymouth podiatry department October 05 Podiatry
Now)
Does the title Diabetes Podiatrist/DSP/Consultant Podiatrist (Diabetes) penalise
other high risk patients who do not have diabetes by restricting their access to
services?
Drivers for Diabetes Specialist Podiatry:
In your opinion, what factors have influenced the development of diabetes
specialist podiatry?
Role of the Diabetes Specialist Podiatrist
Outline for me the roles and functions you undertake as a Diabetes Specialist
Podiatrist.
In your experience, are these roles undertaken by any other professional
groups?
In what ways do you consider the Diabetes Specialist Podiatrists’ role to be different from that of other (generalist) podiatrists?
What do you think distinguishes Diabetes Specialist Podiatry from general podiatry? – at the organisational and career path level
Issues around sustainability:
To your knowledge, how long have Diabetes Specialist Podiatrist posts been established?
246
For how many hours per week are you employed in your specialist diabetes
podiatry capacity?
Ways of working
In your experience, do Diabetes Specialist Podiatrists work with other
professions?
Tell me about the way you work with other clinicians
– “team” (who are the team members, who leads) – “linking”(which professionals /services do you link with)
In your experience, how is care planning undertaken for clients with diabetic
foot disease?
Who leads your foot clinic?
Accessing Diabetes Specialist Podiatry services
From whom do you take referrals?
In your experience, when do (general) podiatrists refer clients to your diabetes
podiatry service?
Education and/or experience
What specific skills and knowledge do you require in your specialised work?
How did you gain this knowledge and these skills?
What education do you consider to be a pre-requisite for the post of Diabetes Specialist Podiatrist?
What education is available to you?
Which educational courses and activities have you found the most useful?
Would you envisage additional training for supplementary prescribing if
altering insulin regimes becomes part of the Diabetes Specialist Podiatrists’ remit?
-What form do you consider such training may take?
What experience do you consider to be a pre-requisite for the post of Diabetes
Specialist Podiatrist?
Status/remuneration
In your experience what grade and salary do Diabetes Specialist Podiatrists receive?
What grade and salary do you consider appropriate for Diabetes Specialist Podiatrists and why?
Vision of ideal Diabetes Specialist Podiatrist role + barriers
Having spoken about the current reality, what is your vision of the ideal Diabetes Specialist Podiatrist role?
… and the ideal educational preparation for Diabetes Specialist Podiatrists?
What do you think prevents us from achieving this ideal situation?
Snowball sampling
Which other people you feel have a contribution to make concerning the
themes we have discussed today?
Anything else you would like to say or add?
247
Appendix 3d. Interview schedule for key actor interview Skills for Health
representative
Introductory question:
Could you give me a brief overview of your role within Skills for Health?
[Background, illuminates professional role and perspectives of respondent]
How does Skills for Health view specialisms within podiatry?
[Small niche profession, is there scope for specialisms? Can podiatry sustain specialist posts?].
Issues around language and terminology in Diabetes Specialist Podiatry recruitment
and job descriptions:
Which terms would you consider to be the most appropriate in advertising a
DSP post? [Skills for Health perspective on the language and terminology used to describe DSP]
What do you consider to be the effect of advertising for multi-specialist skills?
(i.e. one post to cover diabetes, rheumatology and biomechanics specialist areas - e.g. advertisement for Plymouth podiatry department October 05 Podiatry
Now) [Does this denigrate the skill level and importance of specialisms? or do Skills for Health wish to pursue a more “generic” specialist podiatrist?]
Drivers for Diabetes Specialist Podiatry:
In your opinion, what factors are influencing the development of diabetes specialist podiatry? [Are National Service Frameworks a driver? Is
specialism a means of enhancing Agenda for Change profile of posts? Is specialisation viewed by Skills for Health as a form of career progression? Or
as a professionalisation strategy initiated by the profession of podiatry?]
Role of the Diabetes Specialist Podiatrist
What do you consider to be the roles and functions of a DSP? [Specialised
activities or core podiatry for diabetic clients? Do Skills for health perspectives differ significantly from the managers’ and those of FDUK?]
In what ways do you consider the Diabetes Specialist Podiatrists’ role to be different from that of other (generalist) podiatrists? [What level of practice do
Skills for Health envisage as “specialist activity”?]
What do you think distinguishes Diabetes Specialist Podiatry from general
podiatry? [Do Skills for Health consider that there are differences in the
organisation, professional orientation or career path which is different for Diabetes Specialist Podiatrists?]
Issues around sustainability:
In your opinion, for how many hours per week should a Diabetes Specialist Podiatrists employed in their specialist capacity? [Skills for Health
perspectives on possible mismatch between demand and drive for specialisms. Do services demand specialist roles? Is 5 days a week in specialist diabetes
care possible and sustainable? Is full time DSP activity desirable? --managers in pilot did not consider it to be so, pilot FDUK respondents highlighted the
stressful nature of DSP work]
Ways of working
248
In your opinion, should Diabetes Specialist Podiatrists work with other
professions? [Skills for health perspective on skill mix, isolated or interdisciplinary approach. Is multidisciplinary working considered a pre-
requisite for Diabetes Specialist Podiatry?]
In your opinion, within this setting, should the same roles be undertaken by
more than one professional group? [Skills for Health perspective on boundary blurring and possible impact on inter-professional jurisdictional boundary
issues]
Education and/or experience [craft based models/professionalisation… Is there a sheltered position within the podiatry labour market for Diabetes Specialist
Podiatrists?]
What education do you consider to be a pre-requisite for the post of Diabetes
Specialist Podiatrist? [What level of training do Skills for Health consider appropriate for specialist posts?]
What do you consider to be the impact of the current lack of approved training
for DSPs?
What experience do you consider to be a pre-requisite for the post of Diabetes
Specialist Podiatrist? [What kind and duration of experience do Skills for Health consider appropriate for specialist posts?]
What do you consider to be the impact of the current lack of any formalised career pathway for practitioners to develop specialist skills and status?
Status/remuneration
What grade and salary would Skills for Health consider appropriate for
Diabetes Specialist Podiatrists and why?
What do you consider the impact to be of the current variations in grade and
salary of Diabetes Specialist Podiatrists?
Vision of ideal Diabetes Specialist Podiatrist role + barriers
In an ideal world, how would Skills for Health envisage the role of Diabetes
Specialist Podiatrists? [Vision of Diabetes Specialist Podiatry service in an ideal world – would Diabetes Specialist Podiatrists work in their specialism
full time?; opinions on the future of the service; long-term objectives]
What do you think prevents us from achieving this ideal situation? [what are
the barriers]
Snowball sampling
…and finally are there any other people you feel have a contribution to make
concerning the themes we have discussed today? [Who else should I be talking
to about these themes? Which other groups or individuals would wish to have their voices heard on these matters? Who else may make valuable
contributions to this data?]
Anything you wish to add?
249
Appendix 3e. Interview schedule for key actor diabetologists
Introductory questions: Drivers for Diabetes Specialist Podiatry:
In your opinion, what factors have influenced the development of podiatric
diabetology? [Did the working time directive/new deal for junior doctors play a role – if so how significant was the influence?]
Role of the podiatric diabetologist
What do you consider to be the roles and functions of a podiatric diabetologist? [Specialised activities or core podiatry for diabetic clients? Do perspectives
differ significantly from other respondents? Leadership of diabetes teams]
In your experience, are these roles undertaken by any other professional
groups? (inter-professional jurisdictional boundary issues? Leadership of diabetes teams)
Are the podiatrists you work with all specialists in diabetes or are there some
general podiatrists too? [Differences between podiatric diabetologists and generalist podiatrists? Are there any facets of podiatric diabetology which can
be clearly identified as “extended scope practice”? or are the roles extensions and refinements of those taught in the undergraduate syllabus and as such
practiced by most podiatrists at some time in their carer?]
What do you consider to be the effect of advertising for multi-specialist skills?
(i.e. one post to cover diabetes, rheumatology and biomechanics specialist areas - e.g. advertisement for Plymouth podiatry department October 05 Podiatry
Now) [Does this denigrate the skill level and importance of specialties?]
Ways of working
Do you and the podiatric diabetologists work with other health professionals?
[skill mix, isolated or interdisciplinary approach; capture organisational differences between services]
How is care planning undertaken for clients with diabetic foot disease? [Joint planning or co-located but separate professions? If joint is this led by one
profession or is it a team process?]
Education and/or experience [craft based models/professionalisation… Is there a sheltered position within the podiatry labour market for podiatric diabetologists?]
What education do you consider to be a pre-requisite for the post of podiatric
diabetologist? [Impact of lack of approved training for “specialists”]
Would you envisage additional training if activities such as altering insulin
regimes becomes part of the podiatric diabetologists’ remit? -What form do you consider such training may take?
What experience do you consider to be a pre-requisite for the post of podiatric diabetologist? [Impact of lack of formalised career pathway for practitioners to
develop specialist skills/status]
Are personal qualities and personality important in podiatric diabetology? [If
not mentioned with other questions – direct enquiry re the importance of
personal qualities/charisma] Titles
In your experience what title has been assigned to podiatrists specialising in diabetes?
250
What do you consider the legal implications of adopting specialist titles to be?
What is your opinion of the title “Podiatric diabetology”[If no response to repeated use of title in interview process to gauge reaction to title]
Have you any knowledge or experience of people who may object to the title “podiatric diabetology”? [issues with title? Why? Knowledge of any others
who may have issues with this title?]
Issues around sustainability:
To your knowledge, how long have podiatric diabetologist posts been
established? [Origins of DSP. Can podiatry sustain specialist posts?]
In your experience, for how many hours per week are most podiatric diabetologists employed in their specialist capacity? [Mismatch between
demand and drive for specialties? Do services demand specialist roles? Is 5 days a week in specialist diabetes care possible and sustainable?]
Accessing DSP services
From whom do podiatric diabetologists take referrals?
In your experience, when do (general) podiatrists refer clients? [How does the
process work? use of guidelines or referral pathway; education for
“community” podiatrists; is a “shared care” model used? Tensions between generalist and specialist podiatrists; why should general podiatrists refer to
podiatric diabetologists?]
Status/remuneration
In your experience what grade and salary do podiatric diabetologists receive?
[does this reflect the documented reality gained from analysis of Diabetes Specialist Podiatry recruitment]
What grade and salary do you consider appropriate for podiatric diabetologists and why?
Vision of ideal podiatric diabetologist’s role + barriers
Having spoken about the current reality, what is your vision of the ideal
podiatric diabetologist’s role? [Vision of Diabetes Specialist Podiatry service in
an ideal world – would further delegation of tasks and roles be a feature, would podiatric diabetologist work in their specialty full time?; aspirations for
the future of the service; long-term objectives]
What do you think prevents us from achieving this ideal situation? [what are
the barriers?]
Competency Framework
What is your opinion of the proposed competency framework for the prevention , treatment and management of diabetic foot disease (2010)?
Snowball sampling
…my final question, which other people you feel have a contribution to make concerning the themes we have discussed today? [Who else should I be talking
to about these themes? Which other groups or individuals would wish to have their voices heard on these matters? Who else may make valuable
contributions to this data?] Anything you wish to add …
251
Appendix 3f. Interview schedule for key actor “iconic” podiatrist (no longer
practicing)
Introductory questions:
How did you become a podiatric diabetologist?
What are your particular interests in the field of Diabetes Specialist Podiatry?
Drivers for Diabetes Specialist Podiatry:
In your opinion, what factors have influenced the development of podiatric
diabetology? [Are National Service Frameworks a driver? Is specialism a means of enhancing Agenda for Change profile of posts? Is specialisation seen
as a form of career progression?]
Role of the podiatric diabetologist
What do you consider to be the roles and functions of a podiatric diabetologist?
[Specialised activities or core podiatry for diabetic clients? Do perspectives
differ significantly from the managers’ or the FDUK respondents?]
In your experience, are these roles undertaken by any other professional
groups? (inter-professional jurisdictional boundary issues?)
In what ways do you consider the podiatric diabetologists’ role to be different
from that of other (generalist) podiatrists? [are there any facets of podiatric diabetology which can be clearly identified as “extended scope practice”? or
are the roles extensions and refinements of those taught in the undergraduate syllabus and as such practiced by most podiatrists at some time in their carer?]
What do you think distinguishes podiatric diabetology from general podiatry?
[is there anything about the organisation, professional orientation or career path which is different for podiatric diabetologists?]
Ways of working
In your experience, do podiatric diabetologists work with other professions?
[skill mix, isolated or interdisciplinary approach; capture organisational
differences between services]
In your experience, how is care planning undertaken for clients with diabetic
foot disease? [Joint planning or co-located but separate professions? If joint is this led by one profession or is it a team process?]
Education and/or experience [craft based models/professionalisation… Is there a
sheltered position within the podiatry labour market for podiatric diabetologists?]
What education do you consider to be a pre-requisite for the post of podiatric
diabetologist? [Impact of lack of approved training for “specialists”]
Would you envisage additional training if activities such as altering insulin
regimes becomes part of the podiatric diabetologists’ remit?
-What form do you consider such training may take?
What experience do you consider to be a pre-requisite for the post of podiatric
diabetologist? [Impact of lack of formalised career pathway for practitioners to develop specialist skills/status]
Are personal qualities and personality important in podiatric diabetology? [If not mentioned with other questions – direct enquiry re the importance of
personal qualities/charisma]
252
Title
In your experience what titles have been assigned to podiatrists specialising in
diabetes?
In your opinion what are the legal implications of adopting specialist titles?
“Podiatric diabetology” [issues with title? Why? Knowledge of any others who
may have issues with this title?]
Does including “diabetes” in the title restrict access to services for non-
diabetic, high-risk patients?
Issues around sustainability:
To your knowledge, how long have podiatric diabetologist posts been established? [Origins of DSP. Can podiatry sustain specialist posts?]
In your experience, for how many hours per week are most podiatric diabetologists employed in their specialist capacity? [Mismatch between
demand and drive for specialties? Do services demand specialist roles? Is 5 days a week in specialist diabetes care possible and sustainable?]
Accessing DSP services
To your knowledge, from whom do podiatric diabetologists take referrals?
In your experience, when do (general) podiatrists refer clients to a service where podiatric diabetology is established? [How does the process work? use
of guidelines or referral pathway; education for “community” podiatrists; is a “shared care” model used? Tensions between generalist and specialist
podiatrists; why should general podiatrists refer to podiatric diabetologists?]
Status/remuneration
In your experience what grade and salary do podiatric diabetologists receive?
[does this reflect the documented reality gained from analysis of Diabetes Specialist Podiatry recruitment]
What grade and salary do you consider appropriate for podiatric diabetologists and why?
Vision of ideal Diabetes Specialist Podiatrist role + barriers
Having spoken about the current reality, what is your vision of the ideal
podiatric diabetologist’s role? [Vision of Diabetes Specialist Podiatry service in an ideal world – would podiatric diabetologist work in their specialism full
time?; aspirations for the future of the service; long-term objectives]
What do you think prevents us from achieving this ideal situation? [what are
the barriers]
Issues around language and terminology in podiatric diabetologist recruitment and job descriptions: [if there is time]
In your opinion, how accurate is the wording of advertisements for Diabetes Specialist Podiatry posts/job descriptions in describing the role and activities of
Diabetes Specialist Podiatrists? [perspectives on the language and terminology used to describe podiatric diabetology]
Which terms do you consider to be the most appropriate?
What do you consider to be the effect of advertising for multi-specialist skills? (i.e. one post to cover diabetes, rheumatology and biomechanics specialist areas
253
- e.g. advertisement for Plymouth podiatry department October 05 Podiatry Now) [Does this denigrate the skill level and importance of specialisms?]
Skills for Health
What is your opinion of the diabetic foot sections of the Diabetes Framework
produced by Skills for Health? [Competence frameworks “Undertake advanced examination and risk assessment of the feet of an individual with
diabetes” (DF01), “specialist foot treatment for an individual with diabetes” (DF02) and “provide wound care to treat an ulcerated foot of an individual
with diabetes” (DF03)
Snowball sampling
…my final question, which other people you feel have a contribution to make
concerning the themes we have discussed today? [Who else should I be talking to about these themes? Which other groups or individuals would wish to have
their voices heard on these matters? Who else may make valuable contributions to this data?]
Anything you wish to add …
254
Appendix 3g. Interview schedule for key actor SCP
Introductory questions:
Could you give me a brief overview of your role within SCP?
[Background, illuminates professional role and perspectives of respondent]
How does SCP view specialties within podiatry? [Small niche profession, is there scope for specialties? Can podiatry sustain
specialist posts? Divisions within an already small profession? Elitism/fragmentation?].
Drivers for Diabetes Specialist Podiatry:
In your opinion, what factors have influenced the development of podiatric diabetology? [How large was the role of health policy. How significant was
the professional project of podiatrists?]
What was the Societies’ role in developing the Minimum Skills Framework?
[FDUK led and approved by SCP??]
Current status of podiatric diabetology
Why does podiatric diabetology have the status of a special interest group?
What transitions would podiatric diabetology need to undergo to become a
recognised specialty (as opposed to a special interest group within the Faculty of Podiatric Medicine?)
What prevents podiatric diabetology from progressing into a recognised
specialty?
Could podiatric diabetology achieve faculty status as podiatric surgery has
done?
Role of the podiatric diabetologist
What do you consider to be the roles and functions of a podiatric diabetologist?
[Specialised activities or core podiatry for diabetic clients? Do perspectives differ significantly from other respondents?]
Do you consider the roles of the podiatric diabetologist and the generalist podiatrist to differ? If so how are they different? [Differences between
podiatric diabetologists and generalist podiatrists? Are there any facets of podiatric diabetology which can be clearly identified as “extended scope
practice”? or are the roles extensions and refinements of those taught in the undergraduate syllabus and as such practiced by most podiatrists at some time
in their carer?]
What do you consider to be the effect of advertising for multi-specialist skills?
(i.e. one post to cover diabetes, rheumatology and biomechanics specialist areas
- e.g. advertisement for Plymouth podiatry department October 05 Podiatry Now) [Does this denigrate the skill level and importance of specialties?]
Ways of working
What do you consider to be the implications of multi-disciplinary team working for podiatric diabetologists? [skill mix, isolated or interdisciplinary
approach; capture organisational differences between services]
255
Education and/or experience [craft based models/professionalisation… Is there a sheltered position within the podiatry labour market for podiatric diabetologists?]
What education would you consider to be a pre-requisite for the post of
podiatric diabetologist? [Impact of lack of approved training for “specialists”. Explore tensions elicited in other key actor interviews re-education specifically
for podiatric diabetology/ fellowship in podiatric medicine. What specialist knowledge and skills are required? -- are these new or advancements of basic
skills?]
Would you envisage additional training if activities such as altering insulin
regimes becomes part of the podiatric diabetologists’ remit? -What form do you consider such training may take?
What experience would you consider to be a pre-requisite for the post of podiatric diabetologist? [Impact of lack of formalised career pathway for
practitioners to develop specialist skills/status]
Are personal qualities and personality important in podiatric diabetology? [If
not mentioned with other questions – direct enquiry re the importance of
personal qualities/charisma]
Titles
In your experience what titles have been assigned to podiatrists specialising in
diabetes?
What do you consider the legal implications of adopting specialist titles to be?
“Podiatric diabetology” [issues with title? Why? Knowledge of any others who
may have issues with this title?]
Issues around sustainability:
To your knowledge, how long have podiatric diabetologist posts been
established? [Origins of DSP. Can podiatry sustain specialist posts?]
Do you think that podiatry can sustain specialist posts? [if not addressed in
introductory responses]
To your knowledge, for how many hours per week are most podiatric
diabetologists employed in their specialist capacity? [Mismatch between demand and drive for specialties? Do services demand specialist roles? Is 5
days a week in specialist diabetes care possible and sustainable?]
Accessing podiatric diabetology services
Access to podiatric diabetology services seems to vary, how do you think it
should be organised?
How do you view the referral process between generalist podiatrists and
podiatric diabetologists? [How does the process work? use of guidelines or referral pathway; education for “community” podiatrists; is a “shared care”
model used? Tensions between generalist and specialist podiatrists; why should general podiatrists refer to podiatric diabetologists?]
Status/remuneration
In your experience what grade and salary do podiatric diabetologists receive? [does this reflect the documented reality gained from analysis of Diabetes
Specialist Podiatry recruitment]
256
What grade and salary do you consider appropriate for podiatric diabetologists
and why?
Vision of ideal podiatric diabetologist’s role + barriers
Having spoken about the current reality, what is your vision of the ideal
podiatric diabetologist’s role? [Vision of podiatric diabetology service in an ideal world – would further delegation of tasks and roles from medics be a
feature, would podiatric diabetologist work in their specialty full time?; aspirations for the future of the service; long-term objectives]
What do you think prevents us from achieving this ideal situation? [what are the barriers?]
Skills for Health
What is your opinion of the diabetic foot sections of the Diabetes Framework
produced by Skills for Health? [Competence frameworks “Undertake advanced examination and risk assessment of the feet of an individual with
diabetes” (DF01), “specialist foot treatment for an individual with diabetes” (DF02) and “provide wound care to treat an ulcerated foot of an individual
with diabetes” (DF03)
Snowball sampling
…my final question, which other people you feel have a contribution to make
concerning the themes we have discussed today? [Who else should I be talking to about these themes? Which other groups or individuals would wish to have
their voices heard on these matters? Who else may make valuable contributions to this data?]
Anything you wish to add …
257
Appendix 4a.
Research Information Sheet
(Expert Reference Group members)
Study Title: Role definition for diabetes specialist podiatrists
My name is Dawn Bacon; I am a podiatrist undertaking research for an MPhil/PhD
with the School of Health Professions and Rehabilitation Sciences at The University of Southampton. I would like to invite you take part in a research study.
Before you decide whether or not to take part it is important that you understand why
the research is being carried out and what it would involve. Please take time to read the following information. If something is not clear, or you would like further
information please do not hesitate to contact me at the address given above.
Thank you for reading this.
Why have I been approached and what is the purpose of this study?
You have been invited to take part in this study because you belong to a group of
people identified as having key information. The research focuses on what specialisation in diabetes podiatry means in terms of role, ways of working, scope of
practice, accountability, educational preparation, career progression, status and remuneration. Your perspectives on these key issues are extremely valuable.
This study will form part of a larger piece of work, tracing the emergence, shift in
practices over time and current status of diabetes specialist podiatry. The specific aims of this study are:
•To generate a baseline understanding of the role of the Diabetes Specialist Podiatrist,
working towards a role definition with the potential to inform educational, regulatory and remunerative frameworks.
•To provide (non anecdotal) information with the potential to inform service design,
the practice of Diabetes Specialist Podiatrists and other Specialist Podiatrists.
What does this study involve?
You are being invited to take part in a focus group discussion with other members of
the Expert Reference Group. There is currently no clear definition of the role of the
258
Diabetes Specialist Podiatrist; participants should therefore feel free to talk about variations between individuals and services. In choosing a focus group discussion as
a research method it is my aim to include the opinions, views and experiences of all those present; however even if you agree to attend, you do not have to make comments
on any topics that you do not wish to discuss.
So as to minimise any inconvenience for participants, the focus group would take place after one of the Expert Reference Group meetings. I anticipate that the interview
would take approximately one and a half to two hours, depending upon how much participants wish to say. In addition to myself, a research assistant would be present
and proceedings would be audio recorded. Information from the focus group will remain confidential; names will not be disclosed by the researcher or research assistant
under any circumstances. Participants in the focus group will be asked to maintain this confidentiality and to sign a consent form confirming their willingness to do so.
Audio recordings taken during the course of this research will be stored in a locked
cupboard, accessible only to the researcher and her supervisors. Anonymity will be maintained in transcripts of interviews via the use of numerical identifiers or
pseudonyms. Participants will not be identifiable in any papers, presentations or publications derived from the study. When the study finishes, audio recordings and
focus group transcripts will be retained in a secure place at the University of Southampton for fifteen years.
Do I have to take part?
No, there is no compulsion to take part. If you decide to participate, in addition to this
information sheet you will have opportunity to ask questions and clarify details concerning the research. If you do decide to take part, you will be asked to sign a
consent form; however you remain free to withdraw at any time, without giving a reason, and without prejudice.
What are the possible benefits of taking part?
There is no personal benefit of taking part in the study. I hope that the information gained will help to form a baseline understanding of the role, ways of working, scope
of practice, accountability, educational preparation, career progression, status and remuneration of the Diabetes Specialist Podiatrist, and assist in the process of defining
the role of the Diabetes Specialist Podiatrist. Such information, with the potential to inform educational, regulatory and remunerative frameworks at this important time in
health service re-design, may have significant implications for service design, our profession and Diabetes Specialist Podiatry in particular.
Whom do I contact if I have any questions about this research?
If you have any questions or comments about this research please do not hesitate to contact me, Dawn Bacon; by telephone 023 8059 8955 (Mondays and Fridays) or e-
mail [email protected]
259
If you have any concerns about any aspect of the way you have been approached or
treated during the course of this study, the normal University complaints mechanisms are available to you. If you wish to make a complaint please contact Dr Alan
Borthwick, Lecturer at the School of Health Professions and Rehabilitation Sciences, who is supervising my research; Telephone: 023 8059 5904 (e-mail
What will happen to the results of the research?
This research forms part of my PhD and will therefore be available from the British
Library. Papers derived from the research will also be published in peer reviewed journals of interest to podiatrists and other health professionals. Conference
presentations may also be given.
Who has given permission for this research to be undertaken?
The study has been approved by the internal ethics committee of the University of
Southampton. (Ref. No. PO6/11-01). The study is sponsored and underwritten by the University of Southampton.
What do I do next?
I would be very grateful if you would complete the reply slip overleaf indicating whether or not you would like to take part in this research. Please return it to me in the
stamped addressed envelope enclosed. If you indicate that you are interested in taking part, I will contact you again to arrange a time and venue for the interview.
Whether or not wish to take part, if you think that there is a particular person or group
who should be included in this research, please feel free to mention them to me.
Thank you for taking the time to read this letter.
260
Reply sheet: Role definition for diabetes specialist podiatrists
I am* / am not* interested in taking part in a focus group interview
(*PLEASE DELETE AS APPROPRIATE)
Name:…………………………………………………………………………………
Contact Address……………………………………………………………………..
…………………………………………………………………………………………
……………………………......................................Post code……………………
Daytime telephone number…………………………………………………………
E-mail address……………………………………………………………………….
Please return this sheet in the envelope provided to:
Dawn Bacon
Postgraduate office School of Health Professions and Rehabilitation Sciences
University of Southampton Highfield
Southampton, SO17 1BJ
261
Appendix 4b.
Research Information Sheet
(Podiatry Managers)
Study Title: Role definition for diabetes specialist podiatrists
My name is Dawn Bacon; I am a podiatrist undertaking research for an MPhil/PhD
with the School of Health Professions and Rehabilitation Sciences at The University of Southampton. I would like to invite you take part in a research study.
Before you decide whether or not to take part it is important that you understand why
the research is being carried out and what it would involve. Please take time to read the following information. If something is not clear, or you would like further
information please do not hesitate to contact me at the address given above.
Thank you for reading this.
Why have I been approached and what is the purpose of this study?
You have been invited to take part in this study because you are a member of the
Society of Chiropodists and Podiatrists Faculty of Management with experience of employing Diabetes Specialist Podiatrists. The research focuses on what specialisation
in diabetes podiatry means in terms of role, ways of working, scope of practice, accountability, educational preparation, career progression, status and remuneration.
Your perspectives on these key issues are extremely valuable.
This study will form part of a larger piece of work, tracing the emergence, shift in practices over time and current status of diabetes specialist podiatry. The specific aims
of this study are:
•To generate a baseline understanding of the role of the Diabetes Specialist Podiatrist, working towards a role definition with the potential to inform educational, regulatory
and remunerative frameworks.
•To provide (non anecdotal) information with the potential to inform service design, the practice of Diabetes Specialist Podiatrists and other Specialist Podiatrists.
What does this study involve?
You are being invited to take part in a focus group discussion with other managers.
There is currently no clear definition of the role of the Diabetes Specialist Podiatrist;
262
participants should therefore feel free to talk about variations between individuals and services. In choosing a focus group discussion as a research method it is my aim to
include the opinions, views and experiences of all those present; however even if you agree to attend, you do not have to make comments on any topics that you do not wish
discuss.
So as to minimise any inconvenience for participants, the focus group would take place after one of the managers’ meetings held at the Society of Chiropodists and Podiatrists
Offices. I anticipate that the interview would take between one and a half and two hours, depending upon how much participants wish to say. In addition to myself, a
research assistant would be present and proceedings would be audio recorded. Information from the focus group will remain confidential; names will not be disclosed
by the researcher or research assistant under any circumstances. Participants of the focus group will be asked to maintain this confidentiality and to sign a consent form
confirming their willingness to do so.
Audio recordings taken during the course of this research will be stored in a locked cupboard, accessible only to the researcher and her supervisors. Anonymity will be
maintained in transcripts of interviews via the use of numerical identifiers or pseudonyms. Participants will not be identifiable in any papers, presentations or
publications derived from the study. When the study finishes, audio recordings and focus group transcripts will be retained in a secure place at the University of
Southampton for fifteen years.
Do I have to take part?
No, there is no compulsion to take part. If you decide to participate, in addition to this information sheet you will have opportunity to ask questions and clarify details
concerning the research. If you do decide to take part, you will be asked to sign a consent form; however you remain free to withdraw at any time, without giving a
reason, and without prejudice.
What are the possible benefits of taking part?
There is no personal benefit of taking part in the study. I hope that the information
gained will help to form a baseline understanding of the role, ways of working, scope of practice, accountability, educational preparation, career progression, status and
remuneration of the Diabetes Specialist Podiatrist, and assist in the process of defining the role of the Diabetes Specialist Podiatrist. Such information, with the potential to
inform educational, regulatory and remunerative frameworks at this important time in health service re-design, may have significant implications for service design, our
profession and Diabetes Specialist Podiatry in particular.
Whom do I contact if I have any questions about this research?
If you have any questions or comments about this research please do not hesitate to
contact me, Dawn Bacon; by telephone 023 8059 8955 (Mondays and Fridays) or e-mail [email protected]
263
If you have any concerns about any aspect of the way you have been approached or treated during the course of this study, the normal University complaints mechanisms
are available to you. If you wish to make a complaint please contact Dr Alan Borthwick, Lecturer at the School of Health Professions and Rehabilitation Sciences,
who is supervising my research; Telephone: 023 8059 5904 (e-mail [email protected])
What will happen to the results of the research?
This research forms part of my PhD and will therefore be available from the British Library. Papers derived from the research will also be published in peer reviewed
journals of interest to podiatrists and other health professionals. Conference presentations may also be given.
Who has given permission for this research to be undertaken?
The study has been approved by the internal ethics committee of the University of Southampton. (Ref. No. P06/11-01). The study is sponsored and underwritten by the
University of Southampton.
What do I do next?
I would be very grateful if you would complete the reply slip overleaf indicating
whether or not you would like to take part in this research. Please return it to me in the stamped addressed envelope enclosed. If you say that you are interested in taking part
I will contact you again to let you know after which Faculty of Management meeting the focus group will take place.
Whether or not wish to take part, if you think that there is a particular person or group
who should be included in this research, please feel free to mention them to me.
Thank you for taking the time to read this letter.
264
Reply sheet: Role definition for diabetes specialist podiatrists
I am* / am not* interested in taking part in the focus group
(*PLEASE DELETE AS APPROPRIATE)
Name:…………………………………………………………………………………
Contact Address……………………………………………………………………..
…………………………………………………………………………………………
……………………………......................................Post code……………………
Daytime telephone number…………………………………………………………
E-mail address……………………………………………………………………….
Please return this sheet in the envelope provided to:
Dawn Bacon Postgraduate office
School of Health Professions and Rehabilitation Sciences University of Southampton
Highfield Southampton, SO17 1BJ
265
Appendix 4c
Research Information Sheet
(Key Foot in Diabetes UK members)
Study Title: Role definition for diabetes specialist podiatrists
My name is Dawn Bacon; I am a podiatrist undertaking research for an MPhil/PhD
with the School of Health Professions and Rehabilitation Sciences at The University of Southampton. I would like to invite you take part in a research study.
Before you decide whether or not to take part it is important that you understand why
the research is being carried out and what it would involve. Please take time to read the following information. If something is not clear, or you would like further
information please do not hesitate to contact me at the address given above.
Thank you for reading this.
Why have I been approached and what is the purpose of this study?
You have been invited to take part in this study because you are a key member of the
Foot in Diabetes United Kingdom (FDUK) group. The research focuses on what specialisation in diabetes podiatry means in terms of role, ways of working, scope of
practice, accountability, educational preparation, career progression, status and remuneration. Your perspectives on these key issues are extremely valuable.
This study will form part of a larger piece of work, tracing the emergence, shift in
practices over time and current status of diabetes specialist podiatry. The specific aims of this study are:
•To generate a baseline understanding of the role of the Diabetes Specialist Podiatrist,
working towards a role definition with the potential to inform educational, regulatory and remunerative frameworks.
•To provide (non anecdotal) information with the potential to inform service design,
the practice of Diabetes Specialist Podiatrists and other Specialist Podiatrists.
What does this study involve?
You are being invited to take part in a focus group discussion with other members of
FDUK. There is currently no clear definition of the role of the Diabetes Specialist
266
Podiatrist; participants should therefore feel free to talk about variations between individuals and services. In choosing a focus group discussion as a research method it
is my aim to include the opinions, views and experiences of all those present; however even if you agree to attend, you do not have to make comments on any topics that you
do not wish to discuss.
So as to minimise any inconvenience for participants, the focus group would take place after one of the FDUK meetings. I anticipate that the interview would take
approximately one and a half to two hours, depending upon how much participants wish to say. In addition to myself, a research assistant would be present and
proceedings would be audio recorded. Information from the focus group will remain confidential; names will not be disclosed by the researcher or research assistant under
any circumstances. Participants in the focus group will be asked to maintain this confidentiality and to sign a consent form confirming their willingness to do so.
Audio recordings taken during the course of this research will be stored in a locked
cupboard, accessible only to the researcher and her supervisors. Anonymity will be maintained in transcripts of interviews via the use of numerical identifiers or
pseudonyms. Participants will not be identifiable in any papers, presentations or publications derived from the study. When the study finishes, audio recordings and
focus group transcripts will be retained in a secure place at the University of Southampton for fifteen years.
Do I have to take part?
No, there is no compulsion to take part. If you decide to participate, in addition to this
information sheet you will have opportunity to ask questions and clarify details concerning the research. If you do decide to take part, you will be asked to sign a
consent form; however you remain free to withdraw at any time, without giving a reason, and without prejudice.
What are the possible benefits of taking part?
There is no personal benefit of taking part in the study. I hope that the information gained will help to form a baseline understanding of the role, ways of working, scope
of practice, accountability, educational preparation, career progression, status and remuneration of the Diabetes Specialist Podiatrist, and assist in the process of defining
the role of the Diabetes Specialist Podiatrist. Such information, with the potential to inform educational, regulatory and remunerative frameworks at this important time in
health service re-design, may have significant implications for service design, our profession and Diabetes Specialist Podiatry in particular.
Whom do I contact if I have any questions about this research?
If you have any questions or comments about this research please do not hesitate to contact me, Dawn Bacon; by telephone 023 8059 8955 (Mondays and Fridays) or e-
mail [email protected]
267
If you have any concerns about any aspect of the way you have been approached or
treated during the course of this study, the normal University complaints mechanisms are available to you. If you wish to make a complaint please contact Dr Alan
Borthwick, Lecturer at the School of Health Professions and Rehabilitation Sciences, who is supervising my research; Telephone: 023 8059 5904 (e-mail
What will happen to the results of the research?
This research forms part of my PhD and will therefore be available from the British
Library. Papers derived from the research will also be published in peer reviewed journals of interest to podiatrists and other health professionals. Conference
presentations may also be given.
Who has given permission for this research to be undertaken?
The study has been approved by the internal ethics committee of the University of
Southampton. (Ref. No. PO6/11-01). The study is sponsored and underwritten by the University of Southampton.
What do I do next?
I would be very grateful if you would complete the reply slip overleaf indicating whether or not you would like to take part in this research. Please return it to me in the
stamped addressed envelope enclosed. If you indicate that you are interested in taking part, I will contact you again to arrange a time and venue for the interview.
Whether or not wish to take part, if you think that there is a particular person or group
who should be included in this research, please feel free to mention them to me.
Thank you for taking the time to read this letter.
268
Reply sheet: Role definition for diabetes specialist podiatrists
I am* / am not* interested in taking part in a focus group interview
(*PLEASE DELETE AS APPROPRIATE)
Name:…………………………………………………………………………………
Contact Address……………………………………………………………………..
…………………………………………………………………………………………
……………………………......................................Post code……………………
Daytime telephone number…………………………………………………………
E-mail address……………………………………………………………………….
Please return this sheet in the envelope provided to:
Dawn Bacon
Postgraduate office School of Health Professions and Rehabilitation Sciences
University of Southampton Highfield
Southampton, SO17 1BJ
269
Appendix 4d.
Research Information Sheet
(Key actors)
Study Title: Podiatric diabetology: an exploration of the meaning of specialisation in podiatric practice.
My name is Dawn Bacon; I am a podiatrist undertaking research for a PhD with the School of Health Sciences at The University of Southampton. I would like to invite
you take part in a research study.
Before you decide whether or not to take part it is important that you understand why the research is being carried out and what it would involve. Please take time to read
the following information. If something is not clear, or you would like further information please do not hesitate to contact me at the address given above.
Thank you for reading this.
Why have I been approached and what is the purpose of this study?
You have been invited to take part in this study because you have been identified as a
key actor in podiatric diabetology. The research focuses on what specialisation in podiatric diabetology means; exploring facets such as evolution, role, ways of
working, scope of practice, sustainability, accountability, educational preparation, career progression, status and remuneration. Your perspectives on these key issues are
extremely valuable.
This study will form part of a larger piece of work, tracing the emergence, shift in practices over time and current status of podiatric diabetology. The specific aims of
this study are:
To generate an understanding of podiatric diabetology, with the potential to inform educational, regulatory and remunerative frameworks.
To provide (non anecdotal) information with the potential to inform service design and
the practice of podiatric diabetologists.
To explore the impact of specialist titles
270
What does this study involve?
You are being invited to take part in an interview which will focus on what podiatric specialisation in diabetes means in terms of role, ways of working, scope of practice,
accountability, educational preparation, career progression, status and remuneration. In choosing a key actor interview as a research method it is my aim build upon the
baseline understanding of the role of the podiatric diabetologist gained from focus group interviews and to explore themes and issues which arose in these interviews.
So as to minimise any inconvenience for participants, the interview would take place at
a time and venue to suit you. I anticipate that the interview would take approximately an hour, depending upon how much you wish to say. The interview would be audio
recorded. Information from the interview will remain confidential; your name will not be disclosed by the researcher under any circumstances.
Audio recordings taken during the course of this research will be stored in a locked
cupboard, accessible only to the researcher and her supervisors. Anonymity will be maintained in transcripts of interviews via the use of numerical identifiers or
pseudonyms. Participants will not be identifiable in any papers, presentations or publications derived from the study. When the study finishes, audio recordings and
focus group transcripts will be retained in a secure place at the University of Southampton for fifteen years.
Do I have to take part?
No, there is no compulsion to take part. If you decide to participate, in addition to this
information sheet you will have opportunity to ask questions and clarify details concerning the research. If you do decide to take part, you will be asked to sign a
consent form; however you remain free to withdraw at any time, without giving a reason, and without prejudice.
What are the possible benefits of taking part?
There is no personal benefit of taking part in the study. I hope that the information gained will help me to build upon a baseline understanding of the role, ways of
working, scope of practice, accountability, educational preparation, career progression, status and remuneration of the podiatric diabetologist, and assist in the process of
defining the role of the podiatric diabetologist. Such information, with the potential to inform educational, regulatory and remunerative frameworks at this important time in
health service re-design, may have significant implications for services, the profession of podiatry and podiatric diabetology in particular.
Whom do I contact if I have any questions about this research?
If you have any questions or comments about this research please do not hesitate to contact me, Dawn Bacon; by telephone 023 8059 8955 (Mondays and Fridays) or e-
mail [email protected]
271
If you have any concerns about any aspect of the way you have been approached or treated during the course of this study, the normal University complaints mechanisms
are available to you. If you wish to make a complaint please contact Dr Alan Borthwick, Lecturer at the School of Health Sciences, who is supervising my research;
Telephone: 023 8059 5904 (e-mail [email protected])
What will happen to the results of the research?
This research forms part of my PhD and will therefore be available from the British Library. Papers derived from the research will also be published in peer reviewed
journals of interest to podiatrists and other health professionals. Conference presentations may also be given.
Who has given permission for this research to be undertaken?
The study has been approved by the internal ethics committee of the University of Southampton. (Ref. No. P06/11-01). The study is sponsored and underwritten by the
University of Southampton.
What do I do next?
I would be very grateful if you would complete the reply slip overleaf indicating
whether or not you would like to take part in this research. Please return it to me in the stamped addressed envelope enclosed. If you indicate that you are interested in taking
part, I will contact you again to arrange a time and venue for the interview.
Whether or not wish to take part, if you think that there is a particular person or group who should be included in this research, please feel free to mention them to me.
Thank you for taking the time to read this letter.
272
Reply sheet: Podiatric diabetology: an exploration of the meaning of specialisation in podiatric practice.
I am* / am not* interested in taking part in a key actor interview (*PLEASE DELETE AS APPROPRIATE)
Name:…………………………………………………………………………………
Contact Address……………………………………………………………………..
…………………………………………………………………………………………
……………………………......................................Post code……………………
Daytime telephone number…………………………………………………………
E-mail address……………………………………………………………………….
Please return this sheet in the envelope provided to:
Dawn Bacon
Postgraduate office Building 45
School of Health Sciences University of Southampton
Highfield Southampton, SO17 1BJ
273
Appendix 5a.
CONSENT FORM (Focus Group)
Ethics Submission Number P06/11-01 version 3 17.11.06
Title of Project: Role definition for diabetes specialist podiatrists
Name of Researcher: Dawn Bacon
Please initial box
1. I confirm that I have read and understand the information sheet dated 16
th October 2006 for the above study and
have had the opportunity to ask questions.
2. I understand that my participation is voluntary and that I am free to
withdraw at any time
4. I agree to take part in the above study.
5. I agree to the audio- taping of the interview
6. I agree to keep participants’ identities and content
of the discussion confidential.
_________________ _______________ ________________
Name of Respondent Date Signature
________________________ _____________ ___ _________________ Name of Person taking consent Date Signature
(if different from researcher)
_________________________ ________________ _________________ Researcher Date Signature
One copy for Respondent, one for researcher.
274
Appendix 5b.
CONSENT FORM (Key actor)
Ethics Submission Number P06/11-01 version 4 26.06.09
Title of Project: Podiatric diabetology: an exploration of the meaning of
specialisation in podiatric practice.
Name of Researcher: Dawn Bacon
Please initial box
1. I confirm that I have read and understand the information sheet
dated 26th June 2009 for the above study and
have had the opportunity to ask questions.
2. I understand that my participation is voluntary and that I am free to withdraw at any time
4. I agree to take part in the above study.
5. I agree to the audio-taping of the interview.
_________________ _______________ ________________ Name of Respondent Date Signature
________________________ _____________ ___ _________________
Name of Person taking consent Date Signature (if different from researcher)
_________________________ ________________ _________________
Researcher Date Signature
One copy for Respondent, one for researcher.
275
Appendix 6. Example of coding
In w hat w ay do you consider DSP’s role to differ from
>that of generalist pods?
The role is going to be different
DSPs spend majority of their time, a lot of clinical hours>
>gaining experience, hopefully a lot of really enhanced > Learning enhanced clinical reasoning Education input - iterative?
>clinical reasoning skills . Making the right call admissions>
>or tests.
Hospital based specialist has advantage , having additional skills required
Requesting blood tests, interpretation, looking for inflammatory markers
MRIs, x-rays, ultrasound scans, duplex scans – they have a role in that>
>though their ability varies depending on how >
>they’ve used those particular learning opportunities> Education input. Community of practice Education input 232-237 Being part of the hospital diabetes team practice community affords podiatrists the opportunities to learn and acquire additional skills. Relationship betw een
>which occur more in hospital setting than community/primary care Practice community the concepts of eduactional input and practice community
General diabetes advice>
>may be provided in community, how ever>
>hospital setting+ diabetes data+ [test] results+ patient notes>
>privileged to much more information, so>
> decision making, referral and planning is more informed>
Holistic management of specialist pod in hospital setting probably more refined>
>than in community setting – not because of differing abilities>
>because of the environment specialist pod is in – hospital setting.
Chin-wag with physician and a surgeon in a shared clinic Informal education Education input 246 Further overlap w ith Education input, Practice community and Medical patronage
You glean information about the decisions you are making Medical patronage
In a renal unit interpreting BP readings>
>considering degree of ischaemia, f luctuations, chatting about anti-hypertensives>
>there and then you’re [developing] more refined/sophisticated reasoning> Informal education Education input
>making more refined decisions over diff dx, management skills, management planning . Role of DSP Continuum of specialisation
These areas make up the >
>different skill set [of DSP in hospital setting]. Possibly community pods >
>having hospital placements to improve their skills> Access to practice community Education input
>really good idea – part of process enabling others>
>to upgrade skills and become specialist.
Specialist skills – what makes them different = key set of competences Role of DSP Continuum of specialisation
On their ow n they’re just competencies, though important ones
Depending upon enabling physicians in hospital and primary care settings > Enabling physicians Medical patronage 259-266 Medical patronage and membership of a community of practice enables DSPs to develop extended scope skills and to assemble a unique skill-set w hich w ould be
>changing px antibiotics, depending w ho’s doing the supplementary prescribing hard to achieve in any other setting.
Setting up Hickman lines, plaster-casting techniques>
>motivational interview ing – a skill set w hich is more diff icult to acquire>
>and practice on a regular basis, to develop the expertise
If majority of time is spent in hospital setting, treating diabetic patients>
>you have the opportunity [to acquire that skill-set]
>in community setting you may not have these opportunities
276
Appendix 7. Example of Interview Transcript.
D: So in what way do you consider our Diabetes Specialist Podiatrist’s role to be
different from other podiatrists’ – I’m thinking more of the generalist podiatrist
now?
JH: OK, I think well one, one the role’s going to be different in so far as they’re
going to, if they’re going to be spending the majority of their time and a lot of
clinical hours they will go, they will gain by experience, hopefully, a lot of em
[sic] really enhanced clinical reasoning skills and making the right call,
whether its to admit that patient to hospital or whether its to request for hospital
tests for x-rays etcetera. The specialist who’s hospital based is at an advantage
of having additional skills which may be required, for example erm [sic]
requesting blood tests, interpretation of looking for inflammatory markers,
MRIs, x-rays, ultrasound scanning, duplex scanning, they will have a role in
that, with varying degrees of ability depending on how they’ve, em [sic]
depending on what they’ve, how they’ve capitalised and taken advantage of all
those particular learning opportunities which probably occur in a hospital
setting more often than in a community setting, and in primary care. I think the
other aspects would be probably the more general diabetes advice that, that may
well be provided in the community, but when you’re based in a setting in that
hospital setting, and you have all the diabetes data and the results and the
patient notes in front of you, then you’re privileged to, to much more
information, there’s can make a much more informed decision making, in terms
of referral, what to do and, and probably the holistic management of a specialist
podiatrist in that setting, will probably be more refined than in a community
setting, erm [sic] if not because of any particular difference in abilities, just by
sheer dint of the environment thy find themselves in, in a hospital setting. Erm
277
[sic] you may well have a, a chin-wag with the physician and a surgeon in a
multi, in a shared clinic, you will glean information about what’s the decision
you’re making. If you’re in a renal unit and they’re interpreting blood pressure
readings and wondering what degree of ischaemia and, and any fluctuations
and chatting about anti-hypertensives that people, there, there and then you’re
making more refined and more sophisticated reasoning and decisions over
differential diagnosis, and indeed management skills in terms of management
planning as well. So these are some of the areas where I think there, there
could be a different skill set, erm [sic] now whether a community podiatrist
coming through the hospital setting in placement to help to, to improve their
skills I think is a really good idea, and that maybe is part of that whole process
of, of enabling others to, to, to upgrade all their skills to become specialist. But
the specialist skills I think could be, what makes them different, my, it’s a key
set of some competencies, that on their own are just competencies but never-
the-less are quite important ones erm [sic] [sighs] depending on an enabling
physicians in the hospital setting, more so in a primary care setting about
changing prescription antibiotics, about part, depending who’s doing getting
into the supplementary prescribing, setting up Hickman lines, the plaster
casting techniques, erm [sic] motivational interviewing, so, so there are going
to be a, probably a skill set that’s more difficult to acquire and practice on a
regular basis to develop the, the expertise and if you’re spending most of your
time in a hospital treating diabetic patients you’re probably, you have
opportunity to do that. If you’re in a community setting then the chances are
you may not have the same opportunities.